In the last week I have received quite a response to my assertions that the practice of internal medicine is far more difficult to handle for anyone other than a board certified internist.
I speak the truth when I say that real internal medicine cannot be safely practiced by any NP as a full service independent provider, whether they are in the inner city or the middle of BFE, as one commenter called it. Lack of access is simply not an excuse for sending an army of untrained worker bees out to colonize hives that are left empty by the bees that left them behind for greener pastures.
Every time I read a story about how extenders can replace primary care physicians I cringe. Not because NPs are dumb or ignorant. Not because they are incapable of practicing medicine. I cringe because I have come to the conclusion that somewhere along the line internists have been lumped into a category of care that values its service as one that is less than its true meaning. And in many cases, internists have failed their duties as board certified physicians, out of necessity to survive legally and economically.
Primary care has a connotation of simple medicine. A medicine that is first line and only first line. Who's job it is to divvy up disease to be managed by a potpourri of subspecialists waiting in line to get their $200 for passing go. In fact, internists are trained to treat the vast majority of all medical conditions that afflict the majority of adults in this country. Alone. Without any assistance.
Of all the top 10 killers in this country, most patients could be handled to their grave by skilled internists. This is what internists were trained to do. They were not trained to be the front line triage artists. They were trained to be the primary doctor. The doctor that takes care of everything. Not the doctor that decides who else will take care of everything.
Unfortunately, many outpatient internists have abandoned their training in favor of the role of glorified triage nurse extraordinaire. Some have given up their role as the primary physician for everything and instead have fallen victim to the economics of out patient volume medicine, out of economic necessity. Out of legal necessity in this goat rodeo medical complex we practice in. A medicine that only makes you money by seeing more patients, but will make you bankrupt should you fail to follow these rules.
The only way to remain economically viable taking care of sick patients is to send them to someone else in a never ending game of pin the tail on the subspecialist.
Perhaps internists, by choosing this course of action, have no one to blame but themselves for the devaluation of their role in patient care. From a position of economic viability, I don't blame them for a second. A devaluation that leads some to believe that those less qualified are capable of doing what they do. For internists who treat their role as glorified triage nurses, they are guilty of legalized institutional theft from the Medicare National Bank (MNB). They are no better than the rest of the legalized, codified Mafia robbing the unending money supply of the MNB.
For internists who still wish to practice a full scope of outpatient internal medicine. To be the primary doctor for the patient. Their only hope is a fundamental transformation in the way outpatient medicine is paid for. Until internists are paid to provide care, not paid to help others provide care, the goat rodeo will continue. Patients will continue to be poked, prodded, abused, and confused as they are herded from one trough to another where a part of them and their wallet, or America's wallet in the case of the MNB, is picked off in the process.
Those guilty of providing glorified triage nursing have damned centuries of training that few others can master. Those that struggle to maintain the integrity of our field realize, they too will fall without a fundamental restructuring of the outpatient payment model.
Outpatient internists are dying quickly. The way I see it, bundled care, which is essentially concierge medicine, whether funded by state institutions, or funded by private individuals is the only way out of this mess. It must be bundled with gain sharing commitments that give incentives to internists everywhere to do their job and to do it well. When you are paid to do your job, not paid to have others do your job, you will find a much larger satisfaction in your contribution to the equation. You will find your skills will shine. Until then, it may be time for internists to abandon the outpatient ship in favor of a model that pays them for the value they bring to medicine, and let the outpatient model struggle to find cost containment in the glorified triage model of care.
I have found that hospitalist medicine offers me just that.
Every time I read a story about how extenders can replace primary care physicians I cringe. Not because NPs are dumb or ignorant. Not because they are incapable of practicing medicine. I cringe because I have come to the conclusion that somewhere along the line internists have been lumped into a category of care that values its service as one that is less than its true meaning. And in many cases, internists have failed their duties as board certified physicians, out of necessity to survive legally and economically.
Primary care has a connotation of simple medicine. A medicine that is first line and only first line. Who's job it is to divvy up disease to be managed by a potpourri of subspecialists waiting in line to get their $200 for passing go. In fact, internists are trained to treat the vast majority of all medical conditions that afflict the majority of adults in this country. Alone. Without any assistance.
Of all the top 10 killers in this country, most patients could be handled to their grave by skilled internists. This is what internists were trained to do. They were not trained to be the front line triage artists. They were trained to be the primary doctor. The doctor that takes care of everything. Not the doctor that decides who else will take care of everything.
Unfortunately, many outpatient internists have abandoned their training in favor of the role of glorified triage nurse extraordinaire. Some have given up their role as the primary physician for everything and instead have fallen victim to the economics of out patient volume medicine, out of economic necessity. Out of legal necessity in this goat rodeo medical complex we practice in. A medicine that only makes you money by seeing more patients, but will make you bankrupt should you fail to follow these rules.
The only way to remain economically viable taking care of sick patients is to send them to someone else in a never ending game of pin the tail on the subspecialist.
Perhaps internists, by choosing this course of action, have no one to blame but themselves for the devaluation of their role in patient care. From a position of economic viability, I don't blame them for a second. A devaluation that leads some to believe that those less qualified are capable of doing what they do. For internists who treat their role as glorified triage nurses, they are guilty of legalized institutional theft from the Medicare National Bank (MNB). They are no better than the rest of the legalized, codified Mafia robbing the unending money supply of the MNB.
For internists who still wish to practice a full scope of outpatient internal medicine. To be the primary doctor for the patient. Their only hope is a fundamental transformation in the way outpatient medicine is paid for. Until internists are paid to provide care, not paid to help others provide care, the goat rodeo will continue. Patients will continue to be poked, prodded, abused, and confused as they are herded from one trough to another where a part of them and their wallet, or America's wallet in the case of the MNB, is picked off in the process.
Those guilty of providing glorified triage nursing have damned centuries of training that few others can master. Those that struggle to maintain the integrity of our field realize, they too will fall without a fundamental restructuring of the outpatient payment model.
Outpatient internists are dying quickly. The way I see it, bundled care, which is essentially concierge medicine, whether funded by state institutions, or funded by private individuals is the only way out of this mess. It must be bundled with gain sharing commitments that give incentives to internists everywhere to do their job and to do it well. When you are paid to do your job, not paid to have others do your job, you will find a much larger satisfaction in your contribution to the equation. You will find your skills will shine. Until then, it may be time for internists to abandon the outpatient ship in favor of a model that pays them for the value they bring to medicine, and let the outpatient model struggle to find cost containment in the glorified triage model of care.
I have found that hospitalist medicine offers me just that.
Excellent post, Dr. Happy.
ReplyDeleteFinally you made your observational point without dumping on other fields. It may have been at the expense of dumping on the internists, but that point is also true. Primary care docs today do not want to take the risk with their chronic or potentially seriously ill patients anymore, whether it be they don't get paid enough to do it, or they are afraid of the medico-legal. Also, along with that many may be spreading the wealth to their friends/family who are specialists and perhaps with whom they have investments in too? I do know it is darn near impossible to keep up with every possible condition today that might arise or to keep up with the new drugs, combos, and their side effects or interactions with other drugs. This played a part in it also. So in that sense yes, hospitalists do have to be up on their game in a way others don't, and I hope this is not disrespected by others. Just always keep in mind you're not God.
ReplyDeleteIt's all about the money - it always was. Pay docs (and nurses) to do the job well, and they will. Pay them for volume and you'll get volume.
ReplyDeleteSociety has decided that internists are not a valuable resource, so they will go away. The same would happen to football if our society decided to stop paying football players, coaches and referees.
If our society changes it mind and thinks that internists have a value in our culture, it will start to pay for it again.
Internal Medicine is great. The thinking is wonderful. The rapport with patients is invigorating. Retainer medicine is the correction.
ReplyDeleteWho decided that talking to the patient was less valuable than putting a piece of plastic in him?
ReplyDeleteInternist X,
ReplyDeleteI sympathize with your plight. It is rare that I meet an internist who can offer anything but just another referral for another specialty who will report "negative... normal... no significant findings... and nothing more" WTH? There is a lot of "drive-by" doctoring going on, and it has actually caused me (a second career nursing student)to ignore rounding docs for the most part now, as if I don't see them as being of significance?! (just realized this btw after reading your post...) The other day I was doing a full exam on a patient, and a doc wandered in... I was listening to the patient's heart, and noticed the doc's arrival. I didn't move to find a pause point in my exam for a few more minutes, barely gave it a thought. It was as if I felt he was from the lab or something and he could wait?! Please understand, I am not attempting to be flip. My past 20 years of corporate exp. has me quickly determining who is of significance and who is not, that is all. I had made that decision without skipping a beat. How dangerous is that! This is difficult for me. I often feel the need to take over, but cannot of course... I wish more internists would.