Lewis G. Sandy

The Future of General Internal Medicine: Report and Recommendations from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine

The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The task force believes that the chaos and dysfunction that characterize today’s medical care, and the challenges facing general internal medicine, should spur innovation. These are our recommendations: while remaining true to its core values and competencies, general internal medicine should stay both broad and deep—ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases. Postgraduate and continuing education should develop mastery. Wherever they practice, general internists should be able to lead teams and be responsible for the care their teams give, embrace changes in information systems, and aim to provide most of the care their patients require. Current financing of physician services, especially fee-for-service, must be changed to recognize the value of services performed outside the traditional face-to-face visit and give practitioners incentives to improve quality and efficiency, and provide comprehensive, ongoing care. General internal medicine residency training should be reformed to provide both broad and deep medical knowledge, as well as mastery of informatics, management, and team leadership. General internal medicine residents should have options to tailor their final 1 to 2 years to fit their practice goals, often earning a certificate of added qualification (CAQ) in special generalist fields. Research will expand to include practice and operations management, developing more effective shared decision making and transparent medical records, and promoting the close personal connection that both doctors and patients want. We believe these changes constitute a paradigm shift that can benefit patients and the public and reenergize general internal medicine.

Incorporating palliative care into primary care education

SummaryThe confluence of enhanced attention to primary care and palliative care education presents educators with an opportunity to improve both (as well as patient care) through integrated teaching. Improvements in palliative care education will have benefits for dying patients and their families, but will also extend to the care of many other primary care patients, including geriatric patients and those with chronic illnesses, who make up a large proportion of the adult primary care population. In addition, caring for the dying, and teaching others to carry out this task, can be an important vehicle for personal and professional growth and development for both students and their teachers.

Specialty Distribution of U.S. Physicians -- The Invisible Driver of Health Care Costs

Never before have so many Americans been so aware of our health care systems two most glaring defects -- its inability to restrain runaway medical expenditures and its failure to provide basic hea...

The Political Economy Of U.S. Primary Care

Compelling evidence suggests that the United States lags behind other developed nations in the health of its population and the performance of its health care system, partly as a result of a decades-long decline in primary care. This paper outlines the political, economic, policy, and institutional factors behind this decline. A large-scale, multifaceted effort--a new Charter for Primary Care--is required to overcome these forces. There are grounds for optimism for the success of this effort, which is essential to achieving health outcomes and health system performance comparable to those of other industrialized nations.

Primary Care in a New Era: Disillusion and Dissolution?

For decades, health policy experts have bemoaned the beleaguered status of primary care. Rather than building our health care system based on provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing sustained partnerships with patients, and practicing in the context of family and community, (1) our health care system continues to emphasize technologically oriented specialty care. Although this contrast is unremarkable, given the long-standing pro-specialty biases in our medical payment and education systems (2, 3), what is perhaps more surprising is that primary care seems more precarious than ever, even as forces thought to promote it continue to strengthen. Managed care, with its emphasis on cost-effective care for populations, was envisioned by many as a major stimulus to promote primary care. Medical school curricula have evolved to place greater emphasis on early exposures to patients, longitudinal clinical experiences, and clinical clerkships with community-based physicians, all of which are thought to increase interest in primary care. Yet, primary care residency matches were down 3.8% in 2001, the fourth straight year of decline (4). Graduating medical students interest in generalism declined from 40% in 1997 to 32% in 2000 (5) (Figure 1 [6]). Primary care physicians feel beleaguered, and evidence of a primary care backlash is emerging among students and medical school faculty. Figure 1. Interest in generalist specialties among graduating medical students between 1984 and 2000. In fact, the current dilemmas in primary care stem from the unintended consequences of forces thought to promote primary care and the disruptive technologies of care that attack the very concept of primary care itself. These forces, in combination with tiering in the health insurance market, could lead to the dissolution of primary care as a single concept, to be replaced by alignment of clinicians by economic niche, not role. The Assault on Primary Care Ironically, primary care is being assaulted by forces that had been thought to be friendly to itmanaged care and medical education reform. The growth of managed care, particularly capitation, would, the theory went, create new incentives for primary care by increasing income, status, and reputation and by promoting comprehensive and cost-effective care. Under capitation, primary care clinicians would reap real financial rewards for providing continuous, comprehensive, high-quality care by reducing unneeded procedures, hospitalizations, and speciality services. Medical education reform, with an emphasis on early patient care experiences and curriculum changes beyond biomedical science, would also promote primary care (7). In reality, although managed care dominated the market, payment policy perpetuated a discounted fee-for-service financing system. Few physicians could actually manage care under capitation financing, and the managed care marketplace evolved such that most health maintenance organizations (HMOs) paid physicians discounted fee-for-service rates, as did preferred provider organizations (PPOs). As a result, in 1999, the average physician derived only 17% of revenues from capitation (8). Thus, neither enhanced income nor incentives for cost-effective care came to pass as a result of managed care. The technology-intensive biases of fee-for-service payment continue to penalize physicians with less resort to technology (Figure 2) (9). Figure 2. Mean annual physician net income (in real dollars) after expenses but before taxes from 1981 to 1998. Nonetheless, consumer and clinician anger over gatekeeper arrangements and highly publicized limitations on care in HMOs created a managed care backlash, within which primary care was swept up. Consumers equated quality with choice and began to frame primary care as a barrier to quality, not as an enhancer. Moreover, managed care promoted disruptive technologies in primary care, creating new challenges. As described by Christensen, Bohmer, and Kenagy in their widely cited Harvard Business Review paper, Will Disruptive Innovations Cure Health Care? (10), disruptive innovation in a field occurs from below when less expensive approaches enable a product or service to be delivered faster, better, or cheaper. Managed care promoted the growth of nurse practitioner and physician assistant programs, both to enhance the productivity of physician practice and to offer a more cost-effective form of primary care itself. From 1992 to 1997, this group of health professionals doubled, and further growth is anticipated (Figure 3) (7, 11). Figure 3. Number of nonphysician clinical graduates between 1992 and 2001. Managed care also created the need for hospitals and medical groups to become more efficient in inpatient care, giving rise to the hospitalist movement (12, 13). Although the debate on the virtues of hospitalists continues, the hospitalist movement clearly created an alternative pathway for internists interested in a broad practice that crosses subspecialty boundaries. By 1999, 65% of internists had hospitalists in their communities (14), and the hospitalist movement is projected to grow significantly (15, 16). Most devastating, the policy promise that primary care could increase quality and reduce health care costs was not supported by evidence. Some studies noted that primary care clinicians were not regularly superior in the delivery of secondary preventive services (17), and research continued to show thatnot surprisinglyspecialists are more current in their practices than are primary care physicians (18, 19). Managed cares use of discounts and the health insurance underwriting cycle succeeded in moderating health care costs in the mid-to-late 1990san important object lesson, suggesting that market forces independent of primary care can attack cost inflation (20, 21). Primary care fared scarcely better within the walls of academe. Although many medical schools revised their overt curricula to create a greater balance between generalism and specialism, the hidden curriculum that serves powerfully to socialize learners continued to promote subspecialty training and tertiary care. The population-based approaches of the best managed care organizations, some of which worked in partnership with academic health centers, were overshadowed by more aggressive health plans with limited interest in social mission (22). Finally, the 21st century began with some fundamental dynamics in place in the U.S. health care system: 1) Managed care has not improved the cost, quality, and access issues as its advocates had envisioned; 2) health care costs are bound to escalate in years ahead, driven by demographic forces and new technologies; 3) the public has a powerful appetite for health care that shows no signs of abating; and 4) public policy is adrift, with no evident coherent strategy. Primary Care Circa 2002: Excess Supply Meets Tiered Demand The factors that we have described have combined with the unique dynamics among the health professions to create greater primary care supply than demand. The growth in the overall number of physicians has led the Council on Graduate Medical Education (COGME) and other policy bodies to the new view that no substantial shortage of primary care clinicians currently exists (23). For nonphysician primary care clinicians, the promise of prestige and access to reimbursement has resulted in dramatic growth in the supply of nurse practitioners and physician assistants providing primary care (10). Nurses in particular may find the troubled landscape of primary care a relative nirvana when compared with the problems facing regular hospital nursing practice. As a consequence, nursing leaders have emphasized attainment of advanced credentials and training to increase nursings prestige and scope (24). These nonphysician clinicians, in turn, are augmented by both a wide variety of other health professionals providing alternative medicine and by specialists delivering principal care to their patients with a single chronic condition. Although most persons with private health insurance are in loose managed care arrangements, such as open- network HMOs and PPOs, these arrangements offer little prospect of reining in costs over the long haul. Indeed, after several years of moderation in health care costs, both health insurance premiums and underlying costs increased at nearly double-digit rates in 2001 and 2002 (25). Most analysts believe that employees will gradually assume a greater burden of cost sharing over time and that, should the economy go into prolonged recession, employees will face far greater cost sharing and will have to pay a significant premium for the open access to wide networks that many currently enjoy (26, 27). As a consequence, lower-income workers may increasingly tier into tightly managed HMOs, while higher-paid workers will prefer to pay for greater flexibility. Preliminary evidence suggests that this is already occurring. Gabel and colleagues found that workers in high-wage firms tend to enroll in PPOs and open-ended HMOs (which tend to cost more), while low-wage firms tend to offer traditional HMO coverage (which costs less) (28). Similarly, the percentage of Medicaid recipients in managed care has increased from 10% in 1991 to 56% in 2000 (29, 30). This tiering, predicted some time ago by Reinhardt (31), has become the common wisdom among health care futurists (32). As the system tightens for middle- and low-income groups, however, the affluent (particularly, empowered aging baby boomers) will demand not only free choice of clinician but also the highest level of customer service. Already, some practices offer a medical concierge service in which physicians are only a cell phone call away 24/7; others offer integrative medical practices, which combine traditional western medicine with acupunctu

Subspecialty Leadership at a Time of Specialty Excess

A recent analysis suggests that the United States will face a surplus of 163 000 physicians by the end of the decade and that 85% of that surplus will be specialist physicians [1]. Further, the growth of managed care organizations, which use physicians in proportion to the needs of a defined population, is putting relentless pressure on the market for physician services. These marketplace dynamics have stimulated a major debate about how best to achieve a physician work force that meets the nations needs. Arguments for active management of the physician work force, as opposed to relying solely on market forces, are compelling. First, decisions about choice of specialty are made early in medical training and are heavily influenced by the culture of academic medical centerswhich emphasizes technologically intensive, highly specialized care. Second, practicing physicians face market forces that only incompletely penetrate the ivory tower to affect the size and composition of training programs. Third, the size and composition of training programs are driven primarily by service needs in hospitals, not larger societal goals. Fourth, the current Medicare subsidy for graduate medical education has no strings attached, allowing teaching hospitals to develop and expand training programs with ongoing taxpayer support. Fifth, existing antitrust statutes severely limit the capacity of organized medicine to voluntarily manage graduate medical education. On the other hand, strong arguments for a more laissez faire approach have been made. First, some say that the changing marketplace will rapidly cause shifts in specialty choice and that any centralized mechanism will not have the capacity to adjust as smoothly as the markets invisible hand. Second, the track record of federal efforts in work-force policy is not unblemished, with previous predictions of a physician shortage leading to the growth that has caused our current dilemma. Third, the aging of the population and ongoing innovation in medical science and technology make forecasting particularly hazardous. Fourth, some have cast the move to promote primary care as an anti-intellectual reversion of medical education toward a trade-school approach, as opposed to the scientific practice of medicine. In this context, the formation of the Association of Subspecialty Professors in late 1993 was an important event. Directors of training programs in subspecialty internal medicine are an important and heretofore under-represented constituency in national discussions of work-force reform. As the largest medical specialty, internal medicines decisions and directions have a major effect on the physician work force. Moreover, rapid growth in residency positions has occurred within internal medicine and that growth is concentrated in the subspecialties of internal medicine. Since 1988, residency positions in internal medicine have increased by 11% [2], and total subspecialty positions in internal medicine have increased by 28% (Lyttle CS. Personal communication). In this issue, the Association of Subspecialty Professors presents its position [3] on the role of subspecialty internal medicine in national work-force reform. After making the obvious and undeniable case for subspecialty research, training, and practice, the Association makes many sensible recommendations. It recommends that any national work-force commission include medical educators and other knowledgeable physicians (although their call for exclusivity is problematic). The Association advocates an all-payer pool for graduate medical education, with additional funds allocated to provide staffing for training positions lost through downsizing. Stable funding is recommended for physician-scientists, and quality measurement systems for training programs are advocated. An enhanced role for subspecialists in training primary care physicians is also encouraged. On the other hand, the Associations position paper makes some less credible recommendations and, more importantly, neglects several fundamental issues. For example, its recommendation for need-based modeling of demand implies that the enormous projected oversupply of specialists is an artifact of forecasting methodology, when in fact alternative forecasts, including bottom up, demand-driven models have similar results (Malcolm C. Personal communication). The call to make subspecialty medicine more affordable implies fee reductions or utilization reductions, or both, yet no method to achieve this affordability is specified. The recent growth in internal medicine training programs has been driven by increasing numbers of international medical graduates entering U.S. residency and fellowship programs. Currently, international medical graduates account for 36% of first-year internal medicine training slots [2], and international medical graduates hold 37% of nephrology fellowships and 27% of cardiology fellowships [4] when compared with 23% of all residency positions [5]. The Association is silent about the merits of managing the work force through controlling the total number of training positions or using new policies to restrict entry of international medical graduates into U.S. residency positions. Disturbingly, the Associations paper implies that only the medical subspecialties carry the genetic code for biomedical research, patient care, and education. This view neglects fundamental contributions made by other specialists, as well as contributions made by generalists on health services research; decision analysis; small area variation; costbenefit analysis; biomedical ethics; technology assessment; research design and statistical methods; medical education; physicianpatient interactions; and clinical research in common conditions such as low back pain, syncope, and pneumonia. Equating efforts to increase the production of generalists as an attempt to diminish academic medicines mission of creating and disseminating new knowledge in the service of patients is not logical. No evidence exists that the rapid growth in subspecialty training has expanded the research enterprise; if anything, the opposite has occurredthe number of young investigators applying for R01 grants decreased by 54% between 1985 and 1993 [6]. Changing circumstances of funding by the National Institutes of Health may have been the prime reason for this decline. Nevertheless, reducing the number of subspecialty training slots need not inhibit activities of physician-scientists. Most importantly, subspecialty internal medicine, like all of academic medicine, receives the bulk of its financial support through public sources. Academic medicine has a social contract to provide new knowledge and well-trained practitioners to serve society. It must face the fact that adding too many subspecialists to an already richly supplied specialist pool will increase health care costs and perhaps decrease quality of care. Subspecialty training programs also have a moral responsibility to trainees, one that demands they adjust their training programs to the changing marketplace. Already, one medical school (University of California, Los Angeles) has reduced the size of its subspecialty training programs, focusing on the production of physician-scientists [7]. The timing is right for internal medicine subspecialties to actively participate in the national work-force debate. Their challenge will be to evolve from a reactive posture that merely tries to preserve the status quo toward a coherent vision of subspecialty training for the future. This will likely be a contentious and conflict-ridden process, but it will be essential to ensure ongoing innovation in biomedical research, the production of an appropriate number of highly skilled practitioners, and the capacity to adapt over time to changes in science, academia, and society.