F. Daniel Duffy, MD; Eric S. Holmboe, MD
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Potential Financial Conflicts of Interest: Both authors are employed by the American Board of Internal Medicine.
Requests for Single Reprints: F. Daniel Duffy, MD, American Board of Internal Medicine, 510 Walnut Street, Suite 1700, Philadelphia, PA 19106; e-mail, email@example.com.
Current Author Addresses: Drs. Duffy and Holmboe: American Board of Internal Medicine, 510 Walnut Street, Suite 1700, Philadelphia, PA 19106.
Duffy F., Holmboe E.; What Procedures Should Internists Do?. Ann Intern Med. 2007;146:392-393. doi: 10.7326/0003-4819-146-5-200703060-00012
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Published: Ann Intern Med. 2007;146(5):392-393.
For decades, internal medicine residency training has prepared physicians to be generalists and learning bedside procedures has been an important element of training. In this issue, Wigton and Alguire (1) ask whether practicing internists perform the bedside procedures they were trained to do. The answer is, they are not: On average, internists perform 50% fewer procedures than they did 18 years ago. When only the procedures required for certification by the American Board of Internal Medicine (ABIM) are considered, 26% of internists performed lumbar puncture in 2004 compared with 73% in 1986. The trend also held for thoracentesis (23% vs. 66%) and paracentesis (26% vs. 60%); only arthrocentesis of the knee was done by more than 50%. Even in rural towns, only 8 of the procedures were done by most respondents. Can we trust these findings? Despite a survey response rate of only 56%, the response bias more likely trends toward overrepresenting, not underrepresenting, what procedures internists do.
James S. Kennedy
March 8, 2007
Internists should be procedural diagnosticians as well as cognitive diagnosticians
I am saddened that the editorial "What Procedures Should Internists Do?" does not directly answer the question, other than to give general guidelines that what we should do depends on how we fit into our particular practice system to best serve our patients.
What is especially ironic is that Annals bemoaned the primary care- speciality income gap in a Perspective article just one issue before this one, citing that the number of procedures performed has increased, benefiting the specialists that perform these procedures (The Primary Care"“Specialty Income Gap: Why It Matters - Thomas Bodenheimer, MD; Robert A. Berenson, MD; and Paul Rudolf, MD, JD - 20 February 2007 | Volume 146 Issue 4 | Pages 301-306).
Let's just be honest and say that if a general internist wants to learn or perform a procedure effectively in his private practice that he needs to do an internal medicine-based subspeciality. In fact, if the general internist was smart, he would do just that and delegate primary care "grunt work" to nurse practitioners and physicians assistants who are more than willing to do it. Should they have difficulty, he can see their patients in consult and receive the higher E/M fee associated with these visits.
Look at the dynamics out there. What large tertiary hospital today allows a general internist interpret electrocardiograms or Holter monitors, insert arterial cannula, or float a pulmonary artery catheter? These are reserved for cardiologists or possibly intensivists. Who performs thoracenteses, bronchoscopies, or spirometry interpretations? It's usually the pulmonologist. When was the last time a properly trained general internist allowed to do a colonoscopy using hospital facilites? When a Georgia hospital allowed it in 2002, the gastroenterologists abandoned the hospital to favor another facility with a closed shop (personal communication). Who is paid more, the cognitive or the procedural diagnostician? Bodenheimer's article answered that question.
General internists are no longer the diagnosticians that they were before 1970 since the final diagnosis is usually made by a specialist able to do the diagnostic procedure, just like in the New England Journal of Medicine Clinicopathological Conferences. If we are to reclaim our role as the ultimate diagnostician, internal medicine training will have to change.
Given the complexity of internal medicine and the rising prominence of nurse practitioners/physician assistants, I suggest that we change the internal medicine training program as follows:
1) Require that Internal Medicine training be extended to four years with the last year be focused on procedural training (e.g. bronchoscopy, colonoscopy, upper GI endoscopy, coloposcopy, endometrial biopsy, thoracentesis, chest X-ray interpretation, nuclear study interpretation) necessary to make the general internist the ultimate diagnostician.
2) Advocate with hospitals, malpractice carriers, and the public to allow general internists to perform these procedures in their roles as diagnosticians without retaliation from the subspecialists. That means that general internists should be allowed to interpret chest x-rays in the same manner that emergency room physicians can interpret electrocardiograms.
3) Advocate with CMS and the AMA's CPT committee to assign higher RVUs to cognitive skills like blood smear interpretation, microscopic examination of urine, gram-stain review of sputums, cerebrospinal fluid, and urine, and the like. I'll never forget the day that my ability to interpret blood smears (and compulsive habit of looking at them) allowed me to make an early diagnosis of thrombotic thrombocytopenic purpura that had been missed by other physicians.
4) Develop a mechanism whereby general internists with 3 years of training can undergo one more year of training to attain these procedural skills.
Unless we do this, we minus well give general primary care to the nurse practitioners who are more than willing to see the general public in their drugstore-based "Redi-Clinics" (Bohmer R. The Rise of in-store clinics - threat or opportunity. NEJM 2007 Feb 22;356(8):765- 8(http://content.nejm.org/cgi/content/full/356/8/765).
James S. Kennedy, M.D., C.C.S.
March 15, 2007
Internists' procedures should be determined by the density of specialists where they practice
Deciding which procedures internists do is an important question because the response determines the role of generalists in their communities.
The authors' views seem to draw on the old role of the general internist as general medical consultant for patients with hospital-based illnesses. For these physicians, skills like lumbar puncture, central venous access, endotracheal intubation, among others makes sense. It also makes sense for internists (and family doctors)practicing in areas or that have a scarcity of specialists.
But clearly for many generalists including family physicians, their practices are increasingly limited to caring for patients in their offices; particularly for those who practice in areas where there is an abundance of specialists.
The point is that the delineation of the generalists' role is changing rapidly. For many reasons. Managed care has drastically increased the administrative work that generalists have to deal with. To make matters worse, generalists greatly increase their exposure to malpractice suits when they perform some procedural skills that are better off left in the hands of those who do them frequently, and thus, hopefully with less complications. It is too easy for an opportunistic malpractice attorney to allege that a generalist's bad procedural outcome was due to his or her not having done enough of the procedures. Most physicians would prefer not to have that worry hanging over their heads.
The mordern generalist's role has changed in ways that were unimaginable just a few decades ago.Perhaps the best example is the common use of hospitalists, who when taking care of the patients delegated to them, perform many of the skills mentioned by the authors. Clearly,a new paradigm of the generalist is emerging, one that medical educators may not like but which is happening all the same, as a response to many outside forces that did not exist twenty or thirty years ago.
The generalist of the future will be in many instances, particulary in those areas with a good supply of specialists, be office-based. Preparing generalists for the type of practice that will expected of them depending upon the geographical locale of their practices will be a real challenge. It can be done but will require an ongoing dialogue with practicing physician.
Edward J. Volpintesta
March 16, 2007
Tailoring to the needs of one's practice:Its about time
Perhaps the most important statement made by the authors regarding which procedures internists should do was the one about "tailoring procedural skills to the needs of one's practice".
This concept of "tailoring to the needs of one's practice" is long overdue. It applies not just to procedural skills but to the recertification process --not just for internal medicine but for family practice as well,
Why? It is almost a truism that for practicing, non-academic generalists, who have been in practice for a number of years, their scope of knowledge and skills become narrowed because they limit their practices in some way. Either they use hospitalists for their hospital patients, or they don't feel comfortable treating certain diseases or because there are many specialists in the community who are better qualified.
The point is shouldn't the recertification process be tailored as well to reflect this? It seems senseless to test any kind of generalist on the same scope of knowledge he or she possessed when they finished their residencies. Too many physicians waste time and money taking board review exams, memorizing information they will rarely or never use just to pass a board exam. Not only is this an unnecessary burden but it is way out of sync with reality. Most physicians subject themselves to the recertification process to defend against the possibility of being refused admission to an HMO panel or a hospital staff. Neither are good reasons. Worse, some physicians feel that CME has become a cottage industry more intent on financial gain than anything else.
Furthermore, the recertifcation process should do away with the pass/fail mindset. Physicians already certified, and even those who are "board eligible" should be given ongoing opportunities to improve themselves with knowledge and tailored to their particular practices. Arguably, those who cram or take board review courses actually prolong the inadequacy of the test.
The concept of tailoring to the needs of one's practice needs to be studied for its potential benefits.
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