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

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Letters

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

Affirmative action

Your article on affirmative action as it applies to medical school admissions was vintage PC. ("The backlash against affirmative action," January ACP Observer, p. 1.)

Admissions committees have too often decided they are social engineers responsible for determining who will work as physicians, despite the fact that tax and governmental funds paid by all of the citizens are utilized extensively to educate medical students. It is inappropriate to use public monies for this purpose.

If there is true concern about medical care for the underprivileged, we should instead focus on outlandish medical school tuition and the accompanying medical school debt. Programs that help pay off medical school debt in exchange for service in the military and public sector could help provide care for the underprivileged.

In my experience, affirmative action in medical admissions made many mistakes in the beginning, and it needs to be abandoned. Test scores are clearly not the only sign of a good physician, but efforts to completely abandon indicators of quality are not the answer. Our citizens have spoken, and they do not feel that race-based preferences are appropriate.

Ralph G. Wieland, FACP
Chardon, Ohio

Contradiction on referrals?

Can you explain an apparent contradiction in the January 1998 issue of ACP Observer?

The article on page two ("How hospital perks can violate fraud and abuse laws") states that it is a felony to pay or receive payment to encourage patient referrals. The article on page seven ("How to increase referrals—and your revenue") says that to get more referrals, consultants should consider sending "a small gift at holiday time" or sending lunch to the referring physician's office "to show appreciation for a significant increase in referrals."

Joshua B. Grossman, FACP
Johnson City, Tenn.

Editor's note: ACP's Counsel for Health Policy, Michael Werner, JD, offers the following explanation: "The anti-kickback law applies to Medicare only. It is a criminal statute intended to reduce overutilization that would stem from over-referring. Thus, providing incentives for referrals is illegal. However, there is no bright line test and a nominal gift is OK. Usually, this is of the coffee and doughnuts variety. Sending a nice lunch or Christmas gifts, however, is probably not a good idea."

More on board certification

A letter to the editor in the February ACP Observer ("Board certification," p. 4) contends that "until managed care companies perverted the meaning of board certification by using it as a guarantee of physicians' competence, we accepted it as a professional merit badge." I contend that neither characterization is particularly accurate.

While many managed care plans require board certification in credentialing some or all medical specialists, many do not require such certification for their primary care physicians. This is in part due to the perceived shortage of primary care physicians and the fact that board certification is a HEDIS measure, which is used by health care purchasers to compare health plans.

We might ask ourselves why purchasers of health care would desire board certification. In part, it is because we have not developed better surrogate measures of quality care, so we have no one to blame but ourselves.

The good news is there is still opportunity for physicians to help create the future of health care. Are we ready to face the challenges, or are we going to simply blame others for them?

Steven J. Brown, ACP Member
Media, Pa.

Hospitalists

Over the past two years, my partners and I have experimented with the concept of hospital-based physicians to care for our inpatients. ("Are hospitalists a threat to the identity of internists?" February ACP Observer, p. 2.)

The position has been a voluntary, rotating one that has proven to be challenging and fulfilling. We have opted to continue the concept, with one of us taking on the position full-time while another one of us rotates through the hospital during the mornings on a weekly basis to assist in the morning "crunch" time. This will still allow us to maintain our hospital skills while focusing on outpatient services in the clinic.

While I work as a hospitalist part time, I take exception to plans to promote this form of practice as a new subspecialty. After years of reading how the College plans to rectify some of the negative aspects of the practice and to improve student interest in careers in internal medicine, we now witness a movement that will surely lead to the ultimate demise of our discipline. Internal medicine cannot survive yet another "cut-out."

I trust the College will wisely back off from supporting any interest in certifying hospitalists as a separate specialty.

David J. Young, ACP Member
Holland, Mich.

Many internal medicine residencies remain hospital-based, despite attempts to integrate into them longitudinal outpatient experiences. Given the emphasis that many internal medicine residencies place on the management of sick inpatients, it is not surprising that graduating internal medicine residents and chief residents would gravitate to hospitalist positions, which is what they know best.

When I finished my internal medicine residency 14 years ago, I would have made a superb hospitalist. My preparation for managing sick inpatients was superior to my preparation for managing a busy outpatient practice. Until I gained sufficient experience in the outpatient setting, I was much more confident and knowledgable in the hospital. In fact, it was my inpatient expertise that was often tapped by the family and general practitioners with whom I worked during my first few years out of residency.

After a few years of outpatient experience and decreasing inpatient experience, I became much more adept at outpatient primary care. As one's outpatient primary care practice grows, it becomes more difficult to maintain the required expertise and responsiveness that is required in today's hospital environment.

Hospitalism is an outgrowth of the need to provide efficient, expert care to the fewer and sicker patients who require inpatient services. While the identity of internal medicine in the outpatient setting may be "blurred," as ACP President Harold C. Sox, FACP, noted in the story, the identity of internal medicine in the hospital setting is clear and singular. Only internists have that expertise. There is no other physician specialty that produces the skills needed by hospitalists. Not only is hospitalism a natural outgrowth of internal medicine, it is an inevitable one.

Robert A. Zorowitz, FACP
Decatur, Ga.

Hospitalists represent a natural stage in the evolution of medical practice. Like other types of specialists, they are a response to an increasingly complex area of medicine that is best practiced by those who specialize. Hospitalists have a tremendous potential to make all primary care doctors more efficient and do not threaten the identity of internists any more than they threaten the identity of family practitioners or pediatricians.

Hospitalists enhance the identity of primary care internists for several good reasons. First, the majority of critical decisions about inpatient care are made by specialists, so it is not really necessary for primary care physicians to visit their hospitalized patients. In addition, the time that primary care physicians spend traveling to visit their hospitalized patients could be much better used seeing patients in the office, making house calls or seeing patients in nursing homes.

Because they are in the hospital full time, hospitalists are in a much better position to follow-up on diagnostic procedures and plan therapeutic strategies than primary care doctors. Having primary care doctors more available in their offices will allow them to see many of those patients who end up in emergency rooms because their doctors did not have enough time to see them in their offices.

It is critical that primary care doctors be free to see their patients any time. And there will always be the special patient whose care the primary care doctor will not delegate to a hospitalist.

It will not be long before a specialty board for hospitalist medicine is established.

Edward J. Volpintesta, FACP
Bethel, Conn.

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