The September 2003 issue of ACP Observer contained two letters from internists who fear the demise of their profession. (Letters.) I am sure that many readers didn't find this sentiment surprising. The results of this year's Match indicate that even medical students are taking notice.
To my surprise, however, ACP President Munsey S. Wheby, FACP, said that while there's a crisis of sorts brewing in medicine, "'it's not a crisis of dollars ... ' " ("To revitalize internal medicine, look back to its roots.")
I disagree. Outpatient internal medicine is in crisis because internists have failed to convince their patients and third-party payers of the dollar value of their services.
I also disagree with Dr. Wheby's postulation that we are "uncertain about what exactly defines us and sets us apart from other specialties." While Dr. Wheby writes that internal medicine is facing an identity crisis, I believe that most internists are master "diagnosticians" with an "extensive knowledge of pathophysiology" and practice the "judicious use of resources." Most internists today are just as certain about what defines them as they are about the gross inequities in reimbursement between themselves and specialists.
Does the ACP leadership recognize that outpatient internists are struggling for financial survival? At the July meeting of the Board of Regents, physician reimbursement was on the list of recommended areas for advocacy by ACP. ("Regents discuss revitalizing internal medicine, more.") How effective will this advocacy be when its discussion is relegated to page 12 of ACP Observer? And when the President of the organization believes that our crisis "is not a crisis of dollars," who will be our chief advocate?
The New York Times recently reported that Thomas A. Scully, the administrator of the Centers for Medicare and Medicaid Services, said that when it comes to determining the relative value scale, the most aggressive groups are the specialists. Mr. Scully went on to say that year after year, the specialists come in and make a very strong argument for higher reimbursements, and that they eventually "put a squeeze on the basic office visit."
If internal medicine is going to survive, its leaders must do more to increase its "relative value." ACP's vision statement states the College's goal simply: "To be the recognized leader in education, advocacy and enhancing career satisfaction for internal medicine and its subspecialties." College leaders should recognize that making this vision a reality requires immediate action. The survival of outpatient internal medicine belongs on page 1 of ACP Observer.
Dmitry Opolinsky, ACP Associate
In order to revitalize internal medicine, we must regain respect. Many medical students and physicians see us as little more than "triage doctors" who quickly refer our sick or complicated patients to subspecialists.
General internists have essentially abdicated many of our capabilities to subspecialists, leaving us in the same category as general practitioners, family physicians and even nurse practitioners/physicians assistants. When asked what differentiates us from FPs, I could at one time say that internists have deeper diagnostic skills and a more thorough knowledge of pathophysiology, and are able to provide in-depth management of the sickest patients, up to and including critical care.
Now, most internists consult subspecialists for problems that they can and should manage themselves. Even my own specialty publishes guidelines recommending early referral to nephrologists for management of chronic renal insufficiency. This astounds me!
Any thorough internist can prescribe ACE inhibitors, monitor renal function, treat hypertension and diabetes, and evaluate for underlying causes of renal dysfunction competently and effectively.
I, for one, did not go through medical school and residency to be a triage doctor. I use subspecialists for procedures or problems that I cannot solve, or for treatment that is beyond my specialty, like chemotherapy, but I live and breathe to identify the "zebras" and take care of the sickest patients.
I would never consider handing over my inpatients to a hospitalist. I continue to do procedures that I learned as a resident: endotracheal intubations, ventilator management, lumbar punctures, central lines, Swan-Ganz catheters, temporary pacemakers, cardioversions, stress tests and bone marrow biopsies. My colleagues do not offer many of these procedures.
I say internal medicine should reclaim its turf. Be energetic, thorough, excited and aggressive physicians. Show medical students that internal medicine can be fun and that we actually do things. Demonstrate how the scope of our specialty is intellectually rewarding and spiritually fulfilling.
These things attracted me to internal medicine as a student, and they maintain my enthusiasm in spite of the frustrations of the current practice environment. They can still attract current and future medical students.
Rod M. Duraski, ACP Member
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