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



From the February ACP-ASIM Observer, copyright 2003 by the American College of Physicians-American Society of Internal Medicine.

The effort to attract medical students

The front-page article in the December ACP-ASIM Observer makes some valid points, but factors like "lifestyle" issues, waning reimbursement and overwhelmed practitioners get at only part of the problem internal medicine faces in attracting medical students. ("What can internal medicine do to attract more medical students to careers in primary care?")

Equally important is the failure of the graduate medical education system to prepare young internists for success in today's medical marketplace. The image of a harried practitioner "shoehorning" yet another patient into the schedule reflects just how poorly we prepare our graduates to deal with the real world of medicine. We do a much better job preparing competent clinicians than competent practitioners.

Career demands, reimbursement issues and regulatory hassles are not unique to medicine. While many other industries suffer the same or even worse pressures, physicians seem particularly paralyzed and ineffective at managing them.

One critical difference is that most residency programs do not teach the skills that are a standard part of other professions' core curricula. It is time for graduate medical education to recognize the value of some business management education in training programs.

At Providence Portland Medical Center's internal medicine residency program, we are incorporating business management concepts into our curriculum. That helps our trainees understand that only by developing a new mindset can we physicians bring innovation to our practices.

As long as we rely upon antiquated practice models, we will continue to see harried physicians "pushing paper." By embracing a more entrepreneurial mindset, we can create new practice models that allow us to see more patients, boost revenues, reduce practice hassles and—most importantly—improve patient satisfaction.

A little bit of business management education goes a long way toward a better lifestyle for general internists, and it will help keep the discipline attractive.

Michael A. Patmas, FACP, MMM
Portland, Ore.

I particularly liked the suggestion from Lawrence L. Faltz, FACP, to combine internal medicine with family practice. I would argue that the answer to the primary care problem is combining family practice and internal medicine into one four-year specialty training program.

I have always liked family medicine, but never believed that family practice training programs went into enough depth. When I chose an internal medicine residency program in the '90s, I looked for a program that offered some of the flexibility of family medicine. During my four years of training, I was allowed to take a number of electives so I could tailor the program to my interests.

I completed two rotations in general surgery, six rotations in pediatrics and pediatrics/emergency medicine, and one rotation in ob-gyn. I also completed a number of rotations in emergency medicine.

As a resident, I was able to moonlight much more than my classmates in the general internal medicine track. I also ended up being able to practice emergency medicine for four years after residency.

When I burned out on emergency medicine, I was able to switch to urgent care—thanks in part to my pediatrics training. While I am an internist, I see children and handle minor ob-gyn issues.

Today, I practice urgent care half time and teach half time as director of an osteopathic family medicine training program. My diverse training gave me many more options and has allowed me to do more than take care of elderly people with the same old complications.

My training was a perfect model of combining internal medicine with family practice—and it has broadened my career options.

David Lyon, D.O.
Orange, Calif.

Internal medicine, a significant portion of which is cognitive medicine, probably saves untold millions of medical dollars a year in unnecessary testing and procedures.

Yet internists are inadequately compensated. I believe that internists and medical students recognize this disparity and are being discouraged from careers in internal medicine.

If the Regents and the College are interested in attracting more medical students to internal medicine, it is imperative that they undertake an active advocacy program to reimburse physicians more fairly for cognitive medicine.

While practicing internists know that a career in internal medicine can satisfy in ways that money cannot, better reimbursement never hurts and would certainly help attract future generations of medical students.

George Dermksian, FACP
New York

Malpractice insurance for volunteers

While much has been written about medical malpractice insurance problems, physicians around the country and particularly in Pennsylvania are facing another equally frustrating liability issue.

I retired from solo internal medicine practice last June and joined a charity organization to serve indigent patients on a pro bono basis. I have also been offered part time office work by colleagues taking time off for vacations.

I have met with little help from insurers. While I plan to work only a fraction of my former hours, my insurance premiums would range from 80% of my previous premiums if I worked up to 29 hours a week, to 40% if I worked seven hours a week. Some insurers offer only "claims-made" policies that obligate physicians to buy expensive "tail coverage" if they don't practice for at least five years—something many retired physicians can't commit to.

I have been told that retired physicians who care for their family or charity patients do not legally have to purchase liability coverage. This is laudable, but lawyers have told me that there is nothing to stop charity patients from suing, and that I will be taking risk entirely on my own.

As a result, I find myself between the devil and the deep blue sea. If I practice, I must do so without legal protection. If I do not work, I cannot serve.

The fact that willing doctors are being barred from practice is a reflection of our litigious society and the extremely poor regulation of the malpractice situation in this country. How can a free and enlightened country tolerate such a state of affairs?

Byravan Viswanathan, FACP
Gettysburg, Pa.

Editor's note: At its October meeting last year, the College's Board of Regents approved a resolution to have the College investigate mechanisms to help volunteer physicians who need liability insurance. Several College committees are working to identify solutions to the problem.


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