Eric B. Larson

General internal medicine at the crossroads of prosperity and despair: caring for patients with chronic diseases in an aging society.

During the past quarter century, general internal medicine in the United States has emerged as a vital discipline in the pantheon of academic internal medicine and as an important provider of general care for adults (1). At the start of the 1970s, academic general internal medicine was almost nonexistent and the number of general internal medicine practitioners was dwindling (2). Since then, the field has revitalized, as evidenced by increases in numbers of practitioners, trainees, and a well-established cadre of clinical researchers. However, as the field has seemingly flourished, many worry about general internal medicines future and that of all primary care specialists (3). We hear of demoralized practitioners selling practices, changing practices, leaving practices for other opportunities, or abandoning medicine altogether. Prosperity and despair seem to coexist side-by-side in general internal medicine. General internal medicine arguably could be the specialty most highly valued by the segment of the population that requires the most carethe geriatric population. However, the instability of todays medical marketplace makes the future of general internal medicine uncertain. To thrive, general internal medicine must build on its strengths within the medical marketplace, seize the opportunities offered by demographic changes, and take a primary role in serving the needs of older patients with chronic diseases. Patient Care The need for a cadre of competent generalists to meet patient care needs was the driving force behind the resurgence of general internal medicine that began in the 1970s (4). The preeminence of the randomized trial and the increasing acceptance of more robust clinical epidemiologic methods have expanded the ways in which all practitioners can meet patients needs. But general internal medicine has always been, and continues to be, the integrating discipline par excellence, maintaining the broad perspective on each patients medical situation and keeping that care from being fragmented. Todays generalists are thus faced with the challenge of integrating advances of dizzying speed and complexity across a wide range of areas of internal medicine (a not atypical example is managing anticoagulant therapy for thromboembolic disease in a patient with type 2 diabetes mellitus, coronary artery disease, and asthma). Ironically, as practice becomes more effective and the challenges of weaving together these complex elements of care increase, practitioners have more difficulty earning a living from practice. Increasingly, physicians are no longer self-employed. In the early 1990s, hospitals and delivery systems acquired practices in anticipation of health care reform based on managed competition. These practices and their practitioners now cannot cover their owners expenses. In some markets, these acquired practices do not have the strategic value that their owners anticipated, and many have been abandoned. Employers (and the economics of practice) pressure physicians to work harder and faster. Cognitive services are still relatively undervalued compared with procedural and diagnostic services. Fee schedules do not account for the increasing complexity found in many internal medicine patients. Time pressure probably limits the translation of clinical research results into patient care and challenges adherence to practice guidelines. Pressures to be more time-efficient have also forced many practitioners to abandon the traditional combination of office- and hospital-based practice. In many communities, hospitalists and subspecialists now fill this breach. There is an increasing tendency for patients to change insurance coverage (a recent report stated that one in six patients changes insurance every year) (5). Thus, many forces combine to undermine continuity of care, which has long been seen as important for the effectiveness of primary care, especially in older persons with chronic disease (6, 7). The commitment to excellent patient care has been the strength of general internal medicine. This idealism and commitment could suffer terminal burnout from overwhelming market forces. Physician burnout has gone from a theoretical concern to a well-recognized threat. A comparison survey (8) of California physicians in 1991 and 1996 demonstrated that the proportion of primary care physicians willing to go to medical school again had decreased steeply, from 79% in 1991 to 61% in 1996, whereas the proportions for specialists changed very little (68% vs. 63%). Research Research in general internal medicine, as well as support for that research, was virtually nonexistent in 1975. General internal medicine research is now robust, a leader in many departments of medicine and a source of departmental prestige. Further, the results of general internal medicine research have truly changed practice. For example, contrast the relatively nihilistic message of a 1977 article (9), which argued that health services and medical care research didnt make a difference, to today, when research has prompted beneficial changes in practice that are literally too numerous to count. Examples range from research-based strategies defining more effective use of common diagnostic tests for patients with sore throat (10) and other common problems (11) and more precise use of everyday treatments for common conditions (such as bed rest for low back pain [12]) to the more dramatic changes in how we care for patients hospitalized with acute myocardial infarction (13) and patients with venous thrombosis and other thromboembolic diseases (14-16). The care of both outpatients and inpatients at the millennium is almost unrecognizable compared with the treatments we offered 25 years ago. Most important, it is not only the process of care but also the outcomes that are better. Despite these successes, overall research funding for general internists is still relatively modest, especially compared with funding for biomedical and traditional subspecialty research. General medicine research often involves studying chronic disease, and these types of studies often require years. Programmatic research, a paradigm described by Sackett (17) for researchers interested in chronic diseases, depends on collaborations with bridging disciplines, often including biostatistics and social sciences, and requires a substantial infrastructure to support a collaborative group. Building such infrastructures is challenging and expensive. Another threat to research in divisions of general internal medicine is the practice of hiring only clinicians or clinician-teachers in departments of medicine. An increasing, almost unquenchable need to recruit young clinicians to staff growing clinical empires in academic medical centers will increase the total size of academic departments. However, the absence in the ranks of young, entry-level general internist researchers threatens to erase the gains of the past 25 years. This threat to clinical research is hardly unique to academic general internal medicine, but the existence of strong general medicine research programs is a relatively recent phenomenon, making these programs more vulnerable than programs in the subspecialties of internal medicine. Education The teaching ability of general internal medicine faculty has emerged as one of their greatest assets. They are highly visible to students and residents since they provide a disproportionate share of clinically related teaching in many, if not most, schools. They are highly visible and attractive to learners both as inpatient attendings and, increasingly, as role models in the clinic. As clinician-teachers, general internists lead by example in their commitment to evidence-based patient care. However, while education in general internal medicine has improved, weaknesses persist in the broader teaching enterprise. Many teaching programs fail to emphasize the bedside (or deskside) skills most important for clinical practice, despite persuasive narratives (18) and research (19) pointing out deficiencies in traditional training. Technical skills tend to be overemphasized (20). Faculty find it easier to rely on ready-made chalk talks that are suited to faculty interests rather than based on the patients problems or the learners needs (19). Case-based iterative teaching (21) and bedside teaching are used less than they should be (22). Skills training for managing a successful practice is generally not offered, reflecting internal medicines traditional obsession with mastery of medical knowledge to the exclusion of more pragmatic, everyday practice concerns. By contrast, leaders in family medicine have placed more emphasis on successful practice management. Moreover, even with increases in ambulatory clinic experience, most residency programs find it difficult to provide experiential opportunities for their trainees to learn chronic disease management both over time and across several sites. The opportunity to continuously follow single patients with chronic disease is further complicated by the continued emergence of subspecialties within general internal medicinenow including emergency medical specialists, hospitalists, and possibly officistswhich further threatens the traditional primary care emphasis on continuity. Internal medicine residency programs have recently had difficulties adapting to the changing nature of inpatient care in major teaching hospitals. Thus, they offer residents an experience with inpatient general medicine that can be dispiriting and discouraging. Patients admitted to all inpatient teaching services are increasingly ill, and many, particularly on general medical services, have several complex problems or near-terminal conditions. Financial incentives have dramatically reduced the duration of hospitalization, leading to rapid turnover as many patients are transferred as soon as possible to alternative, less expensive sites of care. Housestaff are

Management of Alzheimer's Disease in a Primary Care Setting

This article covers a broad topic from the pragmatic point of view of a primary care physician. The perspective is that of a primary care physician who teaches resident physicians and students in a medical school and for almost 20 years has conducted clinical research in patient care settings, including a large Health Maintenance Organization in Seattle, Washington. This article addresses four general areas that are important for the management of dementia in primary care settings: recognition and diagnosis, treatment in the community (treatment before a person becomes permanently or semipermanently institutionalized), treatment as the disease progresses, and minimization of excess disability.

Recognition of Dementia: Discovering the Silent Epidemic

s there an experienced clinician who has not been surprised I by a patient who turned out to be demented? Most persons who see older patients will admit to having missed dementia more than once. I can still vividly recall an 81-year-old, relatively robust patient I had seen regularly for more than 10 years who developed persistent epigastric pain and weight loss. After an extensive negative evaluation focusing on the possibility of pancreatic cancer, I was surprised to discover after 2 months of frequent visits that the patient was disoriented, had probably been demented for at least 6 months, and most likely had been perseverating on this symptom. The experience of individual clinicians is reflected in a literature more than 2 decades old that emphasizes underrecognition of dementia.’ A paper by Roca and colleagues described underrecognition on a Johns Hopkins inpatient service and has been used to raise awareness in internal medicine.2 The paper by Froehlich et aL3 in this issue ofJAGS cites more recent paper^.^-^ That the phenomenon of underrecognition is widespread is evidenced by epidemiologic surveys. Investigators in the well known East Boston study7 stated that the vast majority of community-based cases were unrecognized.8 A more recent paper’ from the Honolulu Asia Aging Study emphasized the frequency and characteristics of silent dementia among older Japanese-American men. Among 101 noninstitutionalized men, 21 % of family informants failed to recognized a problem with memory among subjects subsequently found to be demented, and 53% of the subjects whose family members did recognize a memory problem did not receive a medical evaluation for the problem. The Honolulu findings are similar in magnitude to those of Callahan et aI.,lo who reported that 76% of subjects found at screening to have moderate to severe dementia were not noted be demented based on chart review. These and other papers confirm that as we approach the millennium, dementia in clinical practice remains, to a considerable extent, the silent epidemic. This phrase was used in 1982 by Peck, Benson et al.” in a seminal paper that focused attention on dementing illnesses as common but largely unrecognized. The aging of our population then, and to an even greater extent now, has led to a growing public health burden, caused by the denicntias, that can truly be characterized as a silent epidemic. The silence persists despite increased publicity about Alzheimer’s Disease, including the public announcement of President Reagan’s diagnosis of Alzheimer’s Disease. Traditionally, medicine has focused on the importance of recognition of dementia primarily to allow prompt treatment of reversible ca~ses.’’~ I believe this emphasis is misplaced, especially given the infrequency of truly reversible dcmentias.12”3 There are more immediate, practical considerations. For practitioners, failure to appreciate impairment in memory and judgment creates a barrier that makes effective patient care difficult, if not impossible. Compliance with treatments, even simple medication regimens, and follow-up will likely be difficult for patients with undetected dementia. Patients with dementia cannot be relied on to report symptoms and are thus at risk of having undetected (and treatable) medical pr0b1ems.l~ For patients and families, safety and security are always an issue. Accidents are almost certainly more common among demented older people. People with dementia are twice as likely as nondemented persons to have automobile accident^.^ Another problem is victimization. We do not have accurate estimates of the frequency with which unprotected older people with dementia fall prey to unscrupulous persons who take advantage of their vulnerability for financial gain. However, our own experience in community-based screening suggests that this is not infrequent. Finally, continued neglect of a progressive dementia in an isolated older person will often lead to a crisis situation characterized by devastation of a person’s health and living situation. What is the solution, or why do we have such a problem? First, providers must realize that patients with cognitive impairment attributable to dementia cannot be expected to report their impairment.’ Although some persons do have insight, many persons with early symptoms do not. Memory

Study of Alzheimer's Dementia Patients with Parkinsonian Features

This paper presents a study to test the hypothesis that a parkinsonian subtype of Alzheimers disease exists. Twenty-one patients with dementia of the Alzheimers type (DAT) and coexistent parkinsonian features were matched to 21 DAT control patients without parkinsonian signs. All subjects were drawn from 136 patients with DAT evaluated between 1980 and 1982. Items from a standardized clinical evaluation at the time of diagnosis, from continuous yearly follow-ups, and neuropathologic examination were compared to determine if qualitative differences exist between the two groups. Those with parkinsonian features had significantly shorter duration of symptoms prior to presentation, a trend toward more reports of decreased self-care, and more primitive reflexes on physical examination. While the total Folstein Mini-Mental State Exam (MMSE) scores at presentation were not significantly different, the cases showed greater impairment in language and registration subitems. During follow-up, no differences were observed in performance on MMSE and Dementia Rating Scale scores. Survival curves showed a trend toward poorer survival in the cases. Neuropathologic data were obtained on seven patients with both DAT and parkinsonian features and showed three cases with Alzheimers disease (AD) alone and four with AD and Parkinsons disease. Four of the DAT control patients were examined neuropathologically, and all had AD without evidence of Parkinsons disease. The results provide preliminary evidence that Alzheimers patients with parkinsonian signs are a subtype characterized by distinct neurologic signs and a more rapid course.

How Can Clinicians Incorporate Research Advances into Practice

I n 1965, my freshman college chemistry lab partner told me an anecdote about his father, a Michigan country doctor, that left an indelible impression. He contrasted the drudgery of a freshman struggling to master college chemistry with the excitement his father experienced at a medical education meeting. The excitement came from how much his dad had learned. He learned how to be a better doctor. He was going to change his practice, and his patients would be better off because of what he had learned. Although it was not apparent to me as a naive freshman, this anecdote is an example of applied learning—new knowledge and research incorporated into practice. More than 30 years later, the practicing physician has the same opportunity: to improve practice based on new knowledge. Today’s practitioner has an array of diagnostic and therapeutic techniques that are quite different from those of my classmate’s father. In addition, the material generated by today’s global medical research enterprise is extensive and expanding rapidly. We continue to experience the same sense of excitement over opportunities to learn of advances that help our patients. We are also, however, probably more aware today of practices that were adapted, only later to be proved ineffective or even harmful. 1,2

Counting plaques and tangles in Alzheimer's disease: Concordance of technicians and pathologists

Our primary aim is to provide a descriptive approach to the analysis of counts of plaques and tangles by different readers. We wanted to find out whether subjects with minimal training can count plaques and tangles in histological specimens of patients with Alzheimers disease and controls. Two experienced neuropathologists trained three student helpers to recognize plaques and tangles in slides obtained from autopsy material. After training, the students and pathologists examined coded slides from patients with Alzheimers disease and controls. Some of the slides were repeated to provide an estimate of reliability. Each reader read four fields which were averaged to obtain estimates of plaque and tangle counts. Raters are compared on four aspects of concordance: location, scale, precision and accuracy. Precision and accuracy are combined to provide an estimate of concordance. We conclude that subjects with minimal training can be taught to count plaques and tangles. Concordance with the neuropathologists was somewhat greater for tangles. This paper also provides a methodology for comparing raters.

General internal medicine update. Information clinicians and teachers need to know.

G eneral internists working to stay current rely on several sources, including journals , cont inuing medical educat ion conferences, and voluntary professional societies, for the latest information. The proliferation of journals and the rapid pace of scientific progress have made it difficult for even the most avid reader and commit ted practi t ioner to review primary information across the entire depth and breadth of general internal medicine. This difficulty explains the popularity of updates , journal clubs, s tate-of-the-art columns, lectures, and publications that summarize information from several journa ls in abstract form. We were asked to prepare an update in general internal medicine this year by both the American College of Physicians (ACP) and the Society of General Internal Medicine. In this essay, we summarize advances made in the last year in eight important areas relevant to general internists. Our method was to survey colleagues and review the ACP Journal Club as well as several major internal medicine journa ls to find published information that general internal medicine practi t ioners and teachers need to know. 1 We deliberately looked for research involving conditions common to general internal medicine practice. We also categorized our information into themes, aiming to concentra te on seven to eight areas of internal medicine. The areas tha t emerged were prevention of coronary artery disease (CAD), management of asymptomat ic carotid stenosis, venous thromboembolism, managemen t of viral diseases, Helicobacter pylori, emergence of drug-resis tant Streptococcus pneumoniae, management of non-insul independent diabetes mell i tus (NIDDM), and management of as thma.