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What is internal medicine's future?

From the March 1998 ACP Observer, copyright © 1998 by the American College of Physicians.

By Deborah Gesensway

There is no doubt that the '90s have brought rapid change to the practice of internal medicine. And although the past is not necessarily prologue, there are some key signs of what the future may hold in store for internists.

Consider the career of James L. Naughton, ACP Member, a general internist in San Francisco's East Bay. Three years ago, his small group practice was the type familiar to most internists, with a mix of generalist and subspecialist internists. Today, the practice has doubled in size (14 physicians and growing) and has metamorphosed into a mix of primary care physicians. There are general internists, family physicians and pediatricians, and only two subspecialists remaining from the original group. This has presented a momentous shift in culture, he said.

"With managed care, you suddenly have an alliance that you didn't know you had before," said Dr. Naughton, a member of the American Board of Internal Medicine (ABIM). "You have a natural affinity with other primary care providers. You share a whole bunch of issues now that you don't have with subspecialists." Is this the direction that the identity of internal medicine will take in the 21st century?

Arif A. Nawaz, ACP Associate, is having to make very different decisions as he plows through his second year of a gastroenterology fellowship at Nassau County Medical Center in Long Island, N.Y. Earlier in his training, he had planned to look for an academic job in the United States. Now, however, Dr. Nawaz, who is vice-chair of ACP's Council of Associates, might very well return to his native Pakistan to find work.

"There's a big surplus of gastroenterologists around the [United States]," he said. "And there's a lot of demand for American-trained physicians back home. I'm undecided." Will the 21st-century marketplace allow internal medicine subspecialties to thrive, or will internal medicine lose its status as the largest U.S. specialty?

And for the lucky ones, nostalgia prevails. James A. Tulsky, ACP Member, got his dream job at Duke University only four and a half years ago, but he is quick to point out that his tenure-track academic slot in general internal medicine-a mix of research, teaching and clinical service—no longer exists at Duke. "In my own institution we don't hire people with a deal like mine anymore," he said.

Today, Dr. Tulsky said, new faculty must either bring in their own funding to do research or they are slotted into positions that require them to see patients 80% to 90% of the time. Will this kind of development in academic institutions change what has been described as the "peculiar and persistently academic tone" that internal medicine has maintained through its first century? What will internists be asked to do in the new century?

Soul searching

Internal medicine's future is at stake largely because of pressure from the general corporatization of health care, and it's hard to find anyone who believes the clock can be turned back. But the specialty's future is also up for grabs due to the soul-searching of internists re-evaluating their strengths—and their roles—in the new health care environment.

How does the quality and cost of the care internists provide stack up to that dispensed either by other primary care providers or by other specialists? And can internal medicine's modus operandi—the overwhelming desire to understand a patient's problems rather than react to the problem directly—survive in a world where money is increasingly scarce?

"We're dealing with a historical transition right now," said Mark A. Kelley, FACP, an internist, critical care physician and vice dean for clinical affairs at Philadelphia's University of Pennsylvania Health System and chairman of ABIM. "Internists were the consummate thinkers and quickly became the ones who brought a lot of the science of medicine forward. ... Then the subspecialist took away that role. At about the same time, along came this nouveau specialty of family practice. Internal medicine has a wide array of agendas underneath it, ranging from the very subspecialist ones to the fundamental primary care ones."

Can the center hold? Maybe not, according to Russell C. Maulitz, ACP Member, a general internist currently working in the family practice department at Allegheny University of the Health Sciences in Philadelphia and a historian of the profession. The future of internal medicine, he said, "is a toss-up right now. I think it's on a knife-edge. Will we become consultants, a là the British model, or will we become broad-based generalists?"

In some ways, none of these questions are new. Internal medicine, after all, has always been the medical specialty with an identity problem. It is a profession that is frequently defined by what it isn't—surgery, pediatrics or gynecology. It is one that medical historians have long said has developed "in relation to—and in reaction to—professional developments in American surgery."

Even in 1897, the father of internal medicine, Sir William Osler, MD, expressed difficulty with the concept: "I wish there were another term to designate the wide field of medical practice which remains after the separation of surgery, midwifery and gynecology," he wrote. "Not a specialty (though it embraces at least half a dozen), its cultivators cannot be called specialists, but bear without reproach the good old name physician, in contradistinction to general practitioners, surgeons, obstetricians and gynecologists."

Internal medicine's identity crisis prompted ACP to launch its "Doctors for Adults" public relations campaign last year, explained ACP's Executive Vice President Walter J. McDonald, FACP. "I think the key to the future isn't the managed care organizations or the employers or the legislators," he said. "It's our patients. If patients are convinced that doctors for adults are what they want, that's what they are going to ask their employers for, and that's what the employers are going to ask the managed care organizations for."

Changing labels

Even if the strategy works in the short term, many health policymakers think that the public is becoming less concerned about what label their health care providers wear, as long as they do the job and give good service. This may become particularly true over the next decade or so as the public learns how to make choices based on performance measures. Patents will care less and less whether their care comes from an internist, a cardiologist, a family physician, a nurse practitioner or some other yet-to-be-labeled provider, explained Robert Berenson, FACP, vice president at The Lewin Group, a Washington, D.C.-based health care management and consulting firm.

"We're having this backlash now that says you get to go to a specialist and that just having a specialty by your name somehow differentiates you, so this [change to an emphasis on performance] will be a long time coming," Dr. Berenson said. "But I think inevitably the whole push for performance-based measures is going to reduce reliance on training as a measure of anything." In the future, he said, "it won't be what your credentials are or what your training is, but whether you can do the job."

For the foreseeable future, there will be a need for doctors of any stripe who are willing to function as primary care physicians. Even with the resurgence of interest in primary care, only about 10% of new physicians are "family practitioners." Even if you don't believe that there is an extreme shortage of generalists, the country still needs more physicians to provide all of its primary care, explained Matthew Holt, a director at the Institute for the Future, a California-based forecasting company.

As a result, many health plans and delivery systems are hungry for primary care providers and don't discriminate against particular specialties. Penn's Dr. Kelley said the University of Pennsylvania Health System has been "blind" as to whether it recruits general internists or family physicians as the primary care physicians of the health system. "We haven't favored one specialty over another," he said.

California's Dr. Naughton said that in communities like his, where there is a great deal of managed care, internists and family physicians have learned that they can do better by banding together rather than going it alone. For internists in his group, which is capitated for roughly half its patients, allying with other specialties has distinct economic advantages in that they can redistribute some of their costs. "The sicker patients tend to end up in the internist's practice," he said. "So the performance under managed care of internal medicine is substantially worse than the family practitioners, in terms of revenue" brought into the practice.

The family physicians get something out of this new alliance too. Internists are typically more familiar with the practice of evidence-based medicine and have led the group in developing protocols and clinical pathways. Also, the practice's five family physicians refer hospitalized patients to their internist colleagues, allowing them to do more of what they mostly want to do—see office patients.

The move toward the hospitalist model, meanwhile, is driving the practice to rethink the role of its internists. Dr. Naughton said that internists have been toying with the idea of referring their patients to hospitalists but do not know how it would work financially. He noted that the scenario raises questions about what internists will be doing in the future, and whether they be will outpatient-only or inpatient-only doctors.

The hospitalist idea is also leading Dr. Naughton's San Francisco group to question whether its structure is the right one for the future. "We may link with other primary care groups who have this model in our area," Dr. Naughton said. A larger and larger primary care group might then explore the option of adding other specialists—for instance, an ob-gyn—and some other medical subspecialists. It all comes when you start to think about the best way to provide comprehensive primary care, he said.

Flexibility

Despite such local successes, most experts predict that no one organizational model will work for internists. It is no longer popular to predict the inexorable rise of a few competing vertically integrated delivery systems—such as that modeled on Kaiser-Permanente—or that all doctors will have to join large multispecialty groups to handle the inevitable takeover of capitation. According to the Institute for the Future's Mr. Holt, the prevailing wisdom is that physicians will work as partners rather than employees.

"My guess is that the most dominant model in 20 years will look more like a collection of law firms—medium-sized partnerships—than big corporations where doctors are employees," Mr. Holt said. "It looks like physician groups are developing that way, but a lot will depend on whether someone proves that one of the models actually works at looking after patients better. ... We are years from being able to say that."

The partnership model is the one that attracted David Ziegler, ACP Associate, as he looked for work this year. When he finishes his general internal medicine residency at the University of South Dakota this spring, he will become the seventh internist in a single-specialty internal medicine group in Sioux Falls. Because he and his fellow residents found primary care jobs in their geographic areas of choice, he is optimistic about the career that stretches ahead of him.

And although Dr. Ziegler always planned to be a primary care doctor, he never considered training in family practice. "I think [internists'] primary role is going to be the primary caregiver for the elderly and also to take care of more complicated problems in patients who have multiple disease processes that need the internist to take care of them," he said. "I think there are a lot of new opportunities for internists."

Internal medicine's "strong foundation for going a lot of different directions" also makes Penn's Dr. Kelley optimistic about the future role of internal medicine in whatever health care delivery system that develops out of the current turmoil.

"I think the internist is a pluripotential person," he said. "Internists win Nobel Prizes, internists are public health officials, internists are taking care of primary care patients, and internists are taking care of critically ill patients. What you will choose to do with that training depends on where you are and what kind of person you are."

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