American College of Physicians: Internal Medicine — Doctors for Adults ®

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Retraining: overcoming the hurdles

From the June 1996 ACP Observer, copyright © 1996 by the American College of Physicians.

By Edward Doyle

Subspecialists face challenges in returning to general practice because their view of the world is so different from generalists', said internists gathered to discuss the advantages—and the pitfalls—of moving from subspecialty practice to general medicine.

While none of the panelists at the session regretted their decision to return to primary care, all said that they encountered serious obstacles in making the change.

Chicago pulmonologist and ACP Regent Whitney W. Addington, FACP, said that general medicine's "culture of uncertainty" continues to challenge him. As a subspecialist, he used to work quickly to establish a diagnosis and treatment plan. In his new life as a generalist, however, Dr. Addington is learning to practice with few diagnostic interventions and few, if any, referrals. "As a generalist, I'm learning that it's more useful to do a few simple things and wait," he said. "I still have problems with the uncertainty."

William J. Hall, FACP, a former pulmonologist from Rochester and ACP Governor for New York who has retrained in general internal medicine, said he considers himself a much better teacher because of his return to generalism, but said he will never be as good a generalist as he was a subspecialist. As a subspecialist, he said, he would instinctively arrive at a diagnosis and be confident it was correct, a knack he fears he may never acquire as a generalist. Plus, he is still disturbed when he has to refer patients to subspecialists who now know more than he does. "I was used to being the expert," he said.

But the panelist who has had the most trouble adapting to his new role as a generalist was Alfred E. Stillman, MACP. Dr. Stillman had practiced as a gastroenterologist for nearly three decades when, due to a complex set of circumstances, he found himself out of work. "The ground was yanked out from me unceremoniously," he said.

After about a year of searching for work in his subspecialty, Dr. Stillman decided to retrain as a generalist. Today he is training as a geriatrics fellow and is finding satisfaction from the different way he views his patients. Dr. Stillman said his goal as a geriatrician is to help patients get the most out of their remaining years. Making the right diagnosis is still important, he said, but only as a way to enhance his patients' lives and not as a goal in itself.

Despite finding satisfaction in his newfound career as a generalist, Dr. Stillman has had his share of struggles. His dealings with younger colleagues—often his supervisors—have been most frustrating. "I need them to be patient with me, and sometimes they're not," he said. "They're sometimes abrupt with me when I don't know something they do."

Age discrimination is an even bigger fear. "Why should an organization take somebody like me who has to learn about new advances in general internal medicine when they can get somebody fresh out of training?" Dr. Stillman asked.

And dealing with the biases of employers, the panelists agreed, could be the biggest hurdle of all for subspecialists ready to return to generalism. Dr. Hall said that physicians need to convince managed care organizations that subspecialists who have kept up their training are capable of providing top-notch primary care services. "Somehow we have to convince them that there are people who perform primary care—and a lot of it—despite the fact that they have subspecialty certificates," he said.

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