Managed care drove him to it
Cardiologist: retraining in primary care the right decision at the right time
By Deborah Gesensway
SAN DIEGO--Stewart L. Frank, MD, was a cardiologist when he went into what he now calls "the most stressful three years of my life." He came out as a general internist. The problem wasn't medicine; it was managed care.
For anyone who will listen, Dr. Frank will take time out of his 12-hour workday to describe the retraining program that guided his professional transformation from a cardiologist who was losing business to an internist with the skills to survive in one of the nation's most competitive medical marketplaces. On this particular day in early May, Dr. Frank's audience is an assistant professor of medicine from Pennsylvania State University College of Medicine in Hershey, Pa. Luanne E. Thorndyke, ACP Member, has flown cross-country in part to visit a couple of the nation's dozen, mostly fledgling, programs dedicated to retraining specialist physicians for new careers in general medicine.
"Either you are going to adapt or be out of business," Dr. Frank tells Dr. Thorndyke over a Greek lunch that serves as a break from the 14 appointments scheduled for the day. His solo practice is part of a 270-physician independent practice association (IPA) called Mercy Physicians Medical Group.
Era of the pragmatist
"The reality is, I'm pragmatic," he says. "I'm shaking myself out. I'm still doing the office-based cardiology. As long as the patients come to me, I'll continue to do it. The marketplace will drive it. But I see the reality, and it is that I'm no longer going to be a pure cardiologist and survive. I'm doing what I think is best for me. And I'm capable of retraining because I've done the general medicine.
"People make changes for two reasons," he continues. "The first is for a great opportunity. The second is only when the fire gets too hot under their feet. In my case it was both. I saw an opportunity, and it was getting hot."
This is not the first chance Dr. Frank has had to express his opinions on the subject. Ever since the health reform debate spotlighted America's subspecialist glut as one of the contributing causes of rising health care costs, Dr. Frank has been fielding telephone calls and entertaining visitors from across the country. They have all wanted to speak with one of the few physicians in the nation who, in conjunction with cost-conscious HMOs, has voluntarily changed his focus from the highly prestigious practice of cardiology to the historically underappreciated practice of general medicine.
Dr. Frank feels confident that his IPA will succeed in helping some of its subspecialists become generalists "because we are retraining people who have been through internal medicine and have a background to do it."
Dr. Thorndyke is inclined to agree with this assessment. She would also add entrepreneurialism as a necessary attribute of the successfully retrained internist; the angry subspecialist who views retraining as a punishment for failing at his or her chosen field, she thinks, is less likely to make the transition well. Dr. Frank, the president of his IPA, clearly is an entrepreneur.
Dr. Thorndyke raises a concern that is central to medical educators working on retraining issues. Conventional wisdom, she explains, holds that the hardest part of retraining specialists to do primary care is teaching them to accept much more uncertainty in their diagnoses and treatment plans. Many internal medicine subspecialists may have the knowledge to practice general internal medicine, but few have the attitude.
Dr. Frank believes himself to be a good example of a subspecialist for whom this was not a problem. Although cardiology had comprised 70% of his 18-year-old practice, general medicine had always been a part of it too.
"I've always done the low backs and the sore throats for my patients, so for me it was no big deal," he says. "I like being a cardiologist, but to be a successful cardiologist today, you mostly have to dedicate yourself to technology and procedures, otherwise you can't call yourself an informed cardiologist. And even the cardiologists who do stents and PTCAs and angioplasties are going to find there's not enough room for them either. We have 13 or 14 cardiologists [in the IPA], and there are maybe going to be five or six who survive."
And Dr. Frank likes the idea of being the kind of doctor whom one patient earlier that morning had consulted about both his circulation and his snoring.
"How young are you?" Dr. Frank had asked the retired political scientist during the 20-minute visit.
"Seventy-eight. And wording it positively won't make me younger," the professor had chastised the physician good naturedly. Having been his patient for years, he trusted Dr. Frank's assessment that the snoring problem did not warrant a consultation with a pulmonologist.
History of a transformation
Published studies during the last few years suggest there will be a glut of perhaps 150,000 specialist physicians beginning in the year 2000. In San Diego, the shakedown has started already. The major transformation in Dr. Frank's practice began about three years ago. "It's Darwin here," he says. "Suddenly there is no guarantee of anybody surviving."
A native New Yorker, Dr. Frank, 50, had moved to San Diego for his internal medicine residency, stayed on for a cardiology fellowship and then decided that there was no place else he would rather live and work. Since the early 1980s, while building his solo practice, Dr. Frank had devoted time to help establish the then-new Mercy Physicians Medical Group. The IPA obtained its first managed care contracts in the late '80s, but it was not until the early '90s that Dr. Frank began hearing from patients that they could no longer visit him because he was not a primary care physician listed with their health plan.
"I went through an initial period thinking it's just a trickle. I won't worry about it. But little by little, the referrals started coming down and the new patients started to go down," he says. His salary dropped to "below six figures" and stayed there.
Fortuitously, at about the same time, Dr. Frank assumed the position of president of the IPA. From his vantage point "on the bow of the ship," as he describes it, "I had a chance to see things happening before most people did." It was then that it began to dawn on him that he was not the only one who might go under; the whole specialist-heavy IPA could fail in this new cost-cutting climate. Of Mercy Physicians' 270 physicians, about one-third do primary care and two-thirds practice in the specialties. Of the 60 internists, about two-thirds are subspecialists. The IPA has contracts with more than 10 HMOs and 20 PPO type health plans, from Aetna to Secure Horizons.
Since HMOs like to form partnerships with medical groups and IPAs that have large numbers of primary care physicians, his thinking was that perhaps some subspecialist internists could be convinced to begin calling themselves generalists. That has been known to happen, after all. In fact, a study published last fall in Annals of Internal Medicine found that 2.2% of specialists during a four-year period in the mid-1980s converted their practices from specialty medicine to general medicine.
Dr. Frank said he could envision himself making the switch. Although he could see himself being happy as an internist who did not do any invasive cardiology, he could not imagine himself as a cardiologist who had given up office practice.
But perhaps, he thought, he might not have to choose. Why shouldn't it be the doctors, not the HMOs, who say who is qualified to provide primary care? And why not do it while speaking the HMO's language? And so was born the idea of a retraining program run by the IPA for its members: The IPA would convince the HMOs to accept all participants in the program as both primary care physicians and specialists by vouching for the doctors' participation in primary care education and monitoring their utilization of services and their costs.
Frederick W. Spong, FACP, Mercy Physicians' medical director at the time, says the program was designed to cause as little disruption as possible in the practicing doctor's life, and to be as personalized as necessary. Dr. Spong is now a consultant with Milliman & Robertson Inc. in San Diego.
Workbooks and workshops
To participate, subspecialists had to be double-boarded in internal medicine and their specialty. They had to agree to participate for 18 months and allow the IPA to monitor their participation and their practices' costs, utilization and services. The doctors assented to capitation for both primary care and subspecialty services. For their part, the HMOs pledged not to drop the doctors from their panels for the duration of the training.
During the 18 months, the retrainees had to attend Mercy's regularly scheduled meetings for primary care providers, which included a number of update sessions on such topics as headaches, low back pain, anxiety and depression. They had to complete a stint on the IPA's utilization review committee. The physicians attended programs and conferences on communication skills, managed care procedures and polices and primary care topics. In addition, they were to work through ACP's MKSAP and other workbooks and arrange one-on-one sessions with specialists in fields such as office gynecology, dermatology and orthopedics.
Reflecting on the retraining program, Dr. Frank says, "I look at it this way. Times are changing. You can't be arrogant. We have to be a little more humble about what is going on. So you retrain. What's the big deal?"
Not everyone in the IPA was of the same opinion. Although five other subspecialists joined the program in 1993, no others have come forward since. In fact, the program contributed to an acrimonious split, with a few subspecialists leaving the IPA to start a competing medical group.
Relations worsened. Some colleagues even stopped referring cardiology patients to Dr. Frank. Capitating everyone in the IPA added to the acrimony. It has been a tough few years, Dr. Frank says, but the group appears to have survived. In fact, one of the doctors who left the IPA now wants back in. And the San Diego market has begun to achieve some equilibrium.
Dr. Frank does not think there will be any reason for the retraining program to continue once the current group completes its work. No other subspecialists in the IPA have expressed any interest, and since the IPA's primary care physicians do not have waiting rooms full of backlogged patients--not yet anyway--there is no need for the group to go out of its way to recruit more of them, he says.
"Some say [what we did] is Mickey Mouse. Some say it was unnecessary. Others said we can build on it," Dr. Frank tells Dr. Thorndyke. He suggests that if she were designing a retraining program for subspecialist internists in Pennsylvania, "you can be more sophisticated about it."
Again referring to his IPA's training, he says, "it wasn't a lot of time, and it satisfied the health plans. It legitimizes us."
Colds and catheterizations
Dr. Frank is hard-pressed to describe how the retraining program changed the way he practices, except that he now does much more primary care, particularly for younger people, than he used to. He only performs about 70 catheterizations a year, and even that amount is decreasing. Since he is fluent in Spanish, having attended medical school in Guadalajara, Mexico, his increased emphasis on primary care has probably helped attract more patients from nearby Mexico.
On the day in May when Dr. Thorndyke visited, Dr. Frank sees six patients with cardiology complaints, two of whom also have secondary primary care problems and questions. Four patients come in specifically for primary care--colds, the removal of a wart, a hepatitis follow-up. Another four appointments are with former or ongoing cardiology patients who have come in for consultations unrelated to their heart.
There is an elderly woman who cannot shake the flu; her husband was a cardiology patient of Dr. Frank's. An older woman arrives for a cardiology follow-up visit; her granddaughter uses the opportunity to talk to the doctor about her headaches and high blood pressure. They decide she should stop taking birth control pills. Is this different from five years ago? A little, Dr. Frank figures, but less than one might think. He says he always did pelvic exams, removed warts, things to make life easier for his patients.
"We're in a service industry," he continues. "I believe that if I take care of the patient, the patient will keep coming back"... as long as the managed care organizations do not get in the way.
He might be willing to emphasize cardiology to a greater or lesser degree in his practice, but Dr. Frank is not ready to abandon the type of mixed internal medicine practice he has worked so hard to build up over the years.
"I was 32 when I went into practice," he says. "So [my practice] is worth fighting for. I'm a pragmatic idealist."
Who is most likely to retrain?
By Deborah Gesensway
At Mercy Physicians Medical Group, the six subspecialists who jumped at the opportunity to retrain in general internal medicine accounted for about 20% of the group's double-boarded internal medicine subspecialists.
That level of interest seems to be shared by many California physicians, according to a new study presented at last spring's Society of General Internal Medicine annual meeting in San Diego.
Sarena Seifer, MD, health policy fellow at the Center for the Health Professions at the University of California, San Francisco, surveyed 475 randomly selected specialist physicians in California who were not employed by managed care organizations and found that a "potential market for retraining does exist in California." About 27% of the internal medicine subspecialists surveyed said they were "likely to retrain in primary care in the next five years." (Forty-nine percent of the ob/gyns expressed a similar interest in primary care retraining.)
The physicians Dr. Seifer found to be interested in retraining were significantly more likely to be the ones, like Dr. Frank, already practicing "some primary care." They also were more likely than their uninterested colleagues to view their practices as "very competitive" and to express dissatisfaction with their job and income. She also found that the interested physicians were more likely to view as important the need to gain additional skills, particularly in practicing ambulatory medicine, in understanding referral issues and in how to incorporate cost data into clinical decision-making.
Part-time study was the only option, according to about 80% of the interested physicians. Only 2% said they saw going back to school, to do a residency or a fellowship, as a viable possibility.
To further understand how much need for retraining exists in other parts of the country, ACP, working with researchers at Albert Einstein medical school, has recently conducted a survey similar to Dr. Seifer's looking at downstate New York. The results of that survey are being analyzed now.
The College is also planning a conference, with funding from the federal Bureau of Health Professions, to explore how subspecialist internists would best be retrained to do general medicine. Scheduled for this winter, the conference will attempt to define "the elements of a gold standard model" for retraining education, according to Kathleen Egan, PhD, of ACP's Education Division, who has been working on career-change education issues for the College.
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