Expand it, shrink it, change it
Training internists for success in the next century
By Jennifer Fisher Wilson
When it comes to training tomorrow's internists, there appear to be two distinct schools of thought.
The first questions whether internists need training in both inpatient and outpatient settings. The emerging role of niche practitioners like hospitalists has moved educators like William T. Branch Jr., ACP Member, primary care internal medicine program director at Emory Health Sciences Center in Atlanta, to consider a split in internal medicine training. If the hospitalist movement catches on, Dr. Branch wonders, how much will in-hospital internists need to train for outpatient work? In the same vein, is it possible that office-based internists of the future should receive mainly ambulatory care training?
In response to interest among residents in his program, Dr. Branch is already considering offering a one-year clinical fellowship in hospitalist medicine. This program will focus on training internists to be experts in delivering effective, high-quality care to a diverse population of patients in the hospital setting. He is also considering a program to provide future office-based internists with an extra year of intensive ambulatory training. Such fellowships might give internists a better chance to handle the new makeup of health care in the future, Dr. Branch said.
Another school of thought, however, says that instead of narrowing the focus of internal medicine training, typical internist skills should be broadened. At Northern California Kaiser Permanente's internal medicine programs, traditional internal medicine competencies like diabetes, gastroenterology and cardiology care have been supplemented with instruction on women's health, adolescent care, musculoskeletal care, routine dermatology, behavioral medicine and psychosocial care. "We're trying to define these as what a doctor for adults does," said Helen L. Hammer, ACP Member, director of graduate medical education at Northern California Kaiser Permanente in Oakland, Calif.
Whether training programs should broaden the scope of internal medicine to make health care more comprehensive or narrow it to a strictly in-hospital or ambulatory care focus, one thing is certain: Internists will have to pay more attention to health care consumers, who want them to run more effective medical practices, and to organizations like hospitals and medical centers, which want internists to lead sophisticated care- delivery systems. Regardless of the changes suggested, educators, medical directors and health care consultants all agree that training changes of some sort must occur in the following five areas if internists are going to succeed in the next century:
The changing system of health care delivery will put a stronger emphasis on internists' ability to communicate with other health care professionals about care plans and referrals.
Being part of a team approach to care is going to be very important for internists who succeed in the future, according to James L. Reinertsen, FACP, the CEO and president of Health System Minnesota. "The way you get better care is not just that you know more and you're a better doctor individually, but also that you can work to improve the process in which the care is occurring," he said.
For internists, the growing emphasis on teamwork will mean the chance to take the leadership role in managing patients throughout the health care system. "Some internists, particularly subspecialists, will be more responsible for not only delivering specialized care, but also for designing the way that care is given throughout the rest of the care-delivery system," said Dr. Reinertsen. As an example, he said that subspecialty internists in particular will be responsible for designing disease-specific systems to enhance how health care teams treat patients who have specific diseases.
An important ingredient of the team approach will be continuous quality improvement tactics, which savvy physicians will use to design and lead delivery models. Internists should expect to learn how to measure outcomes and improvement, stay focused on goals and standardize and simplify care processes to make them error-proof. Dr. Reinertsen said such approaches will have to become a standardized part of internal medicine training.
These skills can also help primary care internists improve outcomes in certain patient populations, noted Kaiser's Dr. Hammer. For example, an internist with a large number of diabetic patients, female patients over the age of 50 or elderly patients should be able to manage each of these populations. "Knowing what a population is at risk for and being able to predict what problems they'll have can keep them as healthy as possible and [will] be required," she said.
Focus on 'consumers'
Consumers will expect their doctors to do a better job of explaining treatment options and discussing health care issues. Internists, who, like all doctors, are not known for communicating well with patients, need to improve in this area, said Robert A. Berenson, FACP, vice president of The Lewin Group, a health care consulting group, and clinical associate professor of medicine at Georgetown University.
"Physicians need to know when to be directive and when to be neutral providers of information," he said. Learning to communicate better with patients will also help internists deal with what Dr. Berenson said is an undeniable fact of the future: the commercialization of medicine. Out of necessity, he said, internists will have to become more consumer-oriented and attract consumers with such perks as evening and weekend hours, minimal waiting time for appointments and comfortable waiting rooms. If not, they will risk losing patients to more accommodating physicians.
"It's not going to be enough to just be a good clinical doctor," Dr. Berenson said. "You will need to be much more oriented to what your clients want and need as they define it, not how you define it."
Kaiser's Dr. Hammer predicted that in the future, internists—both generalists and subspecialists—will no longer be able to provide only disease-related care. They'll also be expected to manage the care of the healthy adult.
In fact, patients are already expecting comprehensive care from their office-based internists, said Emory's Dr. Branch. "When patients come into the physician with a minor type of office problem in gynecology or orthopedics, for example, they should expect to be well cared for in a single visit by the doctor," he said. "That's delivering comprehensive care, and it's reasonable for residents to expect that they'll be taught how to deliver it." Patients today feel empowered to demand timely, one-stop health care while managed care organizations admonish doctors to deliver it in a cost-effective manner that mimimizes unnecessary referrals. Doctors who don't deliver may face patients and the managed care organizations who threaten to take their business elsewhere.
Finally, professionalism will continue to play a critical role in residency training. "Market pressures will make professionalism more important than ever before," said Dr. Reinertsen. Qualities like integrity, altruism, accountability, excellence and respect for others will help support internists' reputation as top-notch health care providers.
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