Should Internists Leave Primary Care to Family Physicians and Serve as Consultants?

Robert M. Centor, MD; Robert W. Donnell, MD; Désirée Lie, MD, MSE; Robert W. Morrow, MD; Roy M. Poses, MD; Charles P. Vega, MD, FAAFP

Disclosures

September 02, 2010

In This Article

Round One: The Internist Viewpoint

Robert Centor, MD (Internal Medicine)

Most readers know that I love to stir controversy. Today, I plan to start a big one.

Last spring I spent 2 weeks on the road -- the first week at the American College of Physicians meeting and the second week at the Society for General Internal Medicine meeting. I talked with many internists, but several conversations contributed to writing this post. Several leaders also contributed to these ideas, but I will not mention names to protect the innocent.

Here are the main assumptions:

  1. Internists by training excel in care of complex cases;

  2. Pursuing the label of "primary care" back in the 1980s was a major mistake; and

  3. Hospital medicine benefits the true, outpatient primary care physicians, who typically do not have enough hospitalized patients to make hospital visits worthwhile.

I have no objections to internists who want to continue the primary care strategy. However, I believe that we should follow the British Empire model and fully develop the consultant model.

What do I mean by "the consultant model"?

I believe that we should support the development of a specific type of outpatient internist -- one who handles complex patients as their main task. They could just do outpatient consultation and work closely with a hospitalist group, or they could be dualists. They would receive many referrals from hospitalists and some from primary care physicians. These consultants could give advice to primary care physicians on balancing the care of complex patients, or they could assume total care.

We would certainly have to develop a more rational payment system to support these consultants. Many retainer practices serve this function. I have 2 friends in Birmingham who have a small retainer practice that fits this definition. They have markedly restricted their practice and have predominantly complex, sick patients. They work with the hospitalist group, and they come to the hospital to ensure excellent transitions and continuity.

Consultant internists would be experts in all major chronic diseases -- for example, congestive heart failure (CHF), chronic obstructive lung disease (COPD), cirrhosis, diabetes, chronic kidney disease (CKD) -- and their interactions.

If we could design this job properly (and it has been done), we would improve outpatient care and decrease inpatient care. Obviously, our current Resource-Based Relative Value Scale system will not support this model, but I would favor some major demonstration projects to define the appropriate panel size and cost.

Those who enter internal medicine generally accept and enjoy complexity. I believe that we could define the consultant job in such a way to make it highly desirable. It might help primary care physicians who find such patients time-sinks.

In summary, I believe that we should consider dividing outpatient internal medicine into 2 tracks -- consultant and primary care. Now I am ready for both supporting and attacking comments.

Roy Poses, MD (Internal Medicine)

I believe that, until there is a commitment to pay primary care practitioners (family physicians, general internists, and general pediatricians) fairly for all they do for patients and to reduce their bureaucratic load and the challenges to their professional autonomy, that this is an argument about deck chairs on the Titanic.

Robert Centor, MD (Internal Medicine)

My post is not about the deck chairs on the Titanic. It concerns understanding how we develop a job description that fits internal medicine. I argue that primary care is not conducted according to the common parlance (see http://dictionary.reference.com/browse/primary+care), so we need to better define what we do.

Robert Donnell, MD (Internal Medicine)

I agree. This is about the need to better define IM. That means defining it according to its original conception, not what it has devolved into over the past 3 decades. I largely agree with Dr. Centor, although I take issue with the last statement in his post about dividing ambulatory IM into 2 tracks. The consultant model is internal medicine. Of course, this will overlap considerably with a previous roundtable we did about whether IM and FP should be merged.

Roy Poses, MD (Internal Medicine)

Perhaps I was a bit harsh -- I actually like Dr Centor's proposal quite a bit. He has written copiously and intelligently about improving practice models (and also about the negative effects of the current physician payment system, and the current enthusiasm for guidelines and "pay for performance").

But I still think society is far from putting its money where its mouth is about primary care/generalist/cognitive practice in any format. Right now, we all know that the practices in this area are in a state of constant decline because of poor reimbursement, bureaucratic load, and lack of professional autonomy. I see no real enthusiasm by politicians, government agencies, commercial insurance companies, proceduralist physicians, academic medical institutions, drug/device/biotech companies, or anyone else for changing things, partially because change would cost money, and might go against the financial interests of many of those groups. International studies show that countries with much healthier primary care/generalist practice systems provide good care at lower cost. But that lower cost means less money going to a lot of people who have become rich from the current system. Do we really expect them to advocate any increase in support for primary care/generalism?

So it's good to think about better models of practice, but I don't think lack of good practice models caused this problem.

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