The Future of General Internal Medicine

Eric B. Larson, MD, MPH; Stephan D. Fihn, MD, MPH; Lynne M. Kirk, MD; Wendy Levinson, MD; Ronald V. Loge, MD; Eileen Reynolds, MD; Lewis Sandy, MD, MBA; Steven Schroeder, MD; Neil Wenger, MD, MPH; Mark Williams, MD

In This Article

Abstract and Introduction

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today's medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep—ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine.

The Society of General Internal Medicine (SGIM) is dedicated to improving patient care, education, and research in primary care and general internal medicine. The primary care movement of the 1970s reestablished general internal medicine, which grew until the early 1990s;[1] but now many question our field's future.

Practitioners remain committed to providing high-quality primary medical and hospital care and ongoing personal relationships with patients across a broad age group, especially the growing number of seniors, chronically ill adults, and people with multiple diseases. However, many practitioners struggle with low reimbursement, increasing administrative burdens, and demands for brief (5-minute) visits that frustrate doctors and patients.[2] Declining application rates to U.S. medical schools show medicine is less attractive.[3] Anecdotes suggest that debt-laden students entering medical school interested in generalist disciplines, including general internal medicine and especially family medicine, are discouraged by the fields' uncertain financial status[4]—turning instead to ancillary specialties such as anesthesiology, pathology, radiology, and higher paying subspecialties like orthopedics, ophthalmology, cardiology, and gastroenterology.[5]

Like practicing general internists in the community reporting increasing role strain,[6,7,8] many academic general internists now face rising demands for productivity, brief visits, and administrative burdens.[9,10] Academic general internists have increasingly been pressed into clinical service as academic clinical enterprises have expanded.

For patients, the health care environment is rapidly changing, and access to primary care is declining especially for the poor and disadvantaged minorities.[11] Medical science keeps making major strides in the effectiveness of preventive, acute, and chronic care. However, the delivery system is plagued by marked inefficiencies, a quality chasm between the best possible care and routine everyday care,[12] previously undisclosed problems related to medical errors and unsafe systems,[13] and more than 40 million uninsured Americans lacking access to general medical care. Threats of terrorism and global infectious diseases have exposed Americans to the health care system's insufficient preparation for dramatic catastrophic events.[14] People with enough wealth seek "boutique" practitioners offering the care that most insured people once expected as routine. Meanwhile, fewer generalists and specialists accept new Medicare patients because of declining reimbursement rates.[15]