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


September 02, 2010

In This Article

The Final Round

Robert Donnell, MD (Internal Medicine)

The original notion of the internist was based on the model of the consultant-generalist.[1] Although internal medicine has devolved away from that model in recent years, it is exactly the model Dr. Centor seems to be advocating now.

Dr. Morrow's screed spews much heat but adds little light. He apparently thinks the consultant-generalist model is an anachronism. If he would care to offer a rational, fact-based argument against the consultant-generalist model I would love to examine it. A little linear thinking might actually be helpful here.

By the way, multidimensionality in patient care, in case Dr. Morrow hasn't heard, is not an exclusive skill of family practice, nor are the other disciplines (anthropology, philosophy, economics) he mentioned.

I think Dr. Morrow may be erecting a straw man in his comments about payment. No one in this discussion has argued that internists should be paid more than family practitioners. What I am hearing is that the system of relative value units is inappropriate for determining reimbursement to nonprocedure physicians.

Robert Morrow, MD (Family Medicine)

Screed: "A long speech or piece of writing, typically one regarded as tedious." Not only a geezer, not just a useful fool, but tedious! I have graduated!

I have consulted on thousands of patients over the years, and see no theoretical advantage of hospital-based internal medicine training that should produce a better management of the complex patient. That ball is in your evidentiary court, Bob. 

To wit: Any analytic of improved patient outcomes should have a practical, theoretical, and evidentiary basis for how one particular type of provider does it better. We have reams of references for primary care and access improving outcomes, and passing little in practice or theory to support the "complexity consultant internists."

Internists get extraordinarily little psychosocial training in most programs, and currently about 2% enter a generalist path. Those who do are notable for their listening skills; those who don't are notable for their procedural momentum. All residents get less social training than they should, but many family physicians train in neighborhood health centers for their 3 years. It shows.

Robert Centor, MD (Internal Medicine)

Ah, debating straw men. Dr. Morrow creates a straw man argument and then spends several paragraphs attacking the entire field of internal medicine. As I read his piece, he lumps all internists (specialists and subspecialists) into 1 big pot. I believe he's missed the point of my essay.

General internists have the many skills that Dr. Morrow values. I wonder where he thinks internists train. Maybe he was a student at an exclusive private hospital, but my national colleagues work with the same patients that he describes. General internists care for the underserved; they have superb doctor-patient communication skills; they worry about costs every day.

To reiterate my point, on average internists care for patients who have more diagnoses. These patients usually have great complexity of diagnoses, medications, psychosocial issues, and financial issues.

I work in the real world. I see the needs of patients. Whether we should call these internists consultants or comprehensivists, or advanced primary care physicians is not the point. The point is that the most medically complex patients would likely benefit from dedicated internists. I believe internists would like the job -- now we just need someone to pay for this niche.

In no way does this proposal denigrate family physicians. Some family physicians love this complexity and do a great job. Some general internists love this complexity and do a great job. Unfortunately, too many family physicians and general internists no longer want to care for these patients because they take too much time. These patients too often get "lost in transition" -- between the outpatient physician, the ER physician, and the hospitalist. Too often these patients have too many subspecialists. Too often these patients have their diseases treated rather than being treated as a patient who has multiple diseases.

I believe some patients would greatly benefit from having 1 physician follow them inside and outside the hospital walls. It has become too difficult and financially punishing for most primary care physicians to maintain their inpatient practices. These patients are, in my opinion, lost in the middle. I suggest internists because we seem to enjoy these complex patients more (on average). Some family physicians may want to develop such practices also.

But family medicine and internal medicine are not the same. I hope that I never criticize family medicine, but rather point out the unique contributions that each specialty makes to patients. We need good family physicians and we need good internists, but they are different. My proposal tries to highlight these differences. So I reject Dr. Morrow's arguments and stand by my initial essay. And I recommend a nice Oregon Pinot Noir, much more complex than most table wines and very nuanced.


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