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 2: The Family Physicians Respond

Charles Vega, MD (Family Medicine)

I think that Dr. Centor has a good point in regard to the complexity of primary care medical practice. Physicians can drown when they have to provide patient-centered, evidence-based, superior-quality, highly reimbursable care to larger and larger numbers of patients. We all need somebody to lean on, and there is evidence that using other resources to handle responsibilities currently set at default to the physician can improve efficiency and quality.

If all parties (patients, staff, physicians, payors, government) can truly embrace the patient-centered medical home, I think that primary care physicians can do a much better job in managing the complex patients Dr. Centor identifies. A patient with CHF, COPD, cirrhosis, diabetes, and CKD (I have a number of these patients myself) would not be jammed into a 15-minute visit, with all problems on the table and none managed too well. Ideally, the physician would have an hour or more to talk to the patient and set the agenda for ongoing care. Staff can make sure that referrals are followed through. The patient can attend group visits to better understand healthy lifestyles, with the primary teachers being his or her fellow patients along with a dietician or health educator. A nurse will follow glucose checks, body weight, and respiratory symptoms through an online registry, alerting the physician to significant problems.

I don't believe that the trend toward increasingly complex patients in primary care offices will reverse itself anytime soon. Regardless, we need to continue to embrace our role as our patients' first option toward improved well-being. The patient-centered medical home allows us to continue in this role while also increasing the efficiency and quality of care.

Desiree Lie, MD (Family Medicine)

I suggest making this broader to include family physicians (FPs) in the discussion. FPs can be distinguished by those who do specialty work (like obstetrics; sports medicine; geriatrics; and gastrointestinal procedures, such as colonoscopy) but who are not characterized so much by complexity of patients as by the breadth of conditions seen (converting undifferentiated into differentiated problems). There is also a growing number of FP hospitalists. PCPs need to band together through health reform, and not split further hairs and fight over reimbursement from a shrinking pool.

Constructive statements that come from primary care that reduce cost and improve quality for patients will get a hearing. Statements that demand more pay for some, less for others (which would result from creating a "higher"-level PCP, like a consultant) without addressing prevention, quality of care, and health outcomes will probably be ignored. So if a within-specialty split in MD function is proposed, an argument must be made that it is not only cost-effective but also has better long-term clinical and population-based outcomes than the current model. Who will do (or pay for) this study to provide the evidence of efficacy?

Robert Morrow, MD (Family Medicine)

Dr. Centor presents an intriguing taxonomy of medical simplicity-complexity that is like a table wine, accessible and fresh, but lacking depth, maturity, and nuance. I usually avoid these wines.

But here we are, teaching another generation the issues of uncertainty, nonlinearity, and context. The guts of patient care digest these issues daily and are helped by our friends, the symbiotic biota of philosophy, anthropology, math, economics, and [alas] politics.

As a family doc in the community for 35 years, let me assure you that internists do not learn complexity in their silly hospital rotations that preoccupy them, or the endless bickering between partialists who think they are smarter than each other because they have an explanatory model that they think predicts outcomes better than the other partialists. In reality, most partial explanatory models, like most linear philosophies, because of their Newtonian, linear views of people, miss the processes that lead to unexpected outcomes.

Now I do think Newton was cool for his time, and I think fairy tales about coronary stents and PET scans for amyloid and PSA testing and rosiglitazone and "one gene-one disease" and ASA-cures-all were amusing in their time. Critical thinking might have helped us years ago with these.

Forgive me if I don't feel internists have a grasp on the multidimensionality, the biopsychosociality, of patient care that would render them more fit for higher pay -- for "complexity." What do you think we family docs do all day? Wipe noses? We deal with both complexity and uncertainty. We deal with context. We could do better, but who should be paid what for which activity? 

Should consultants be capitated and bear risk for expenditures? That might be fair and save some unnecessary expenditures, many of which come from self-interested procedures.

But I have yet to see a sense of humility in the face of uncertainty and failure that merits special pay for those with the label of "consultant" and who often make simplistic algorithmic decisions to add 1 drug after another, 1 low-accuracy test after another, until the medical bank is bankrupt. Every stupid MRA or coronary CT sucks more bucks out of the important work of healthcare, such as adequate home care and community patient education. 

If internists move their training to neighborhood health centers and share in the real uncertainties of evictions, no insurance, intricate mental health issues, domestic violence, and racial disparities, they can earn the title of "consultant" and join the ranks of modern socially based physicians. Should they get paid more? Oh please. 

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