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The Declining Number and Variety of Procedures Done by General Internists: A Resurvey of Members of the American College of Physicians

Robert S. Wigton, MD; and Patrick Alguire, MD
[+] Article and Author Information

From University of Nebraska Medical Center College of Medicine, Omaha, Nebraska, and the American College of Physicians, Philadelphia, Pennsylvania.


Potential Financial Conflicts of Interest: Royalties: R.S. Wigton (Elsevier, Inc.).

Requests for Single Reprints: Robert S. Wigton, MD, University of Nebraska Medical Center College of Medicine, 984285 Nebraska Medical Center, Omaha, NE 68198-4285; e-mail, wigton@unmc.edu.

Current Author Addresses: Dr. Wigton: University of Nebraska Medical Center College of Medicine, 984285 Nebraska Medical Center, Omaha, NE 68198-4285.

Dr. Alguire: American College of Physicians 190 N. Independence Mall West, Philadelphia, PA 19106-1572.


Ann Intern Med. 2007;146(5):355-360. doi:10.7326/0003-4819-146-5-200703060-00007
Text Size: A A A

Background: A survey of general internist members of the American College of Physicians (ACP) in 1986 found that they did a large number and variety of procedures in their practices. Since then, changes in the practice of medicine, regulatory requirements, and availability of subspecialists may have affected the number and type of procedures done by internists.

Objective: To determine the number and types of procedures currently done by general internist members of the ACP compared with 1986.

Design: Mailed questionnaire.

Setting: National probability sample of general internists.

Participants: Respondents to a national survey of 2500 general internist members of the ACP who were similar in characteristics to those who participated in the 1986 survey. Of the 1389 questionnaires that were returned, 990 were from general internists who had completed the survey.

Measurements: Responses to questions about procedures done and practice characteristics.

Results: The number and variety of procedures done by general internists has decreased dramatically. On average, the percentage of general internists doing each procedure now is less than half of that in 1986. The average number of different procedures done in practice decreased from 16 in 1986 to 7 in 2004. As in the 1986 survey, the number of procedures related strongly to personal and practice characteristics. Internists who practice in smaller towns and smaller hospitals do twice as many procedures on average as those in larger cities and larger hospitals. The number and variety of procedures done by internists also increased with greater time spent in total patient care.

Limitations: The number and type of procedures were determined by self-reporting, not direct observation.

Conclusions: Both the number and variety of procedures done by general internists have decreased considerably since 1986. As in the 1986 survey, general internists who practice in smaller cities and smaller hospitals and those who spend more hours in patient care perform more procedures. Recommendations and practices for internal medicine residency training in procedures should be reexamined in light of these changes.

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The potential for non-response bias
Posted on March 5, 2007
Thomas S. Metkus
University of Pennsylvania School of Medicine
Conflict of Interest: None Declared

To the Editor:

Drs. Wigton and Alguire report an interesting and important survey of general internists (1). Their results suggest that, compared to a survey performed in 1986, internists are performing a lower volume of a less diverse array of procedures (1). The authors do not, however, address the potential for non-response bias in their study. Non-response bias occurs when non-respondents are in some way different from respondents. A high response rate alone does not eliminate this bias (2).

The authors report that non-respondents and respondents were of similar age and sex, but they do not comment on the geographic region or the city size of respondents versus non-respondents. If, for example, fewer rural physicians (who, the authors report, perform a greater number and variety of procedures than their urban counterparts) responded to the survey, the number of procedures reported by respondents would be less than the true number performed by the population. This bias would inflate the difference between the number of procedures performed in 1986 and the present, potentially affecting the authors' stated conclusions that the "number and variety of procedures done by general internists have decreased considerably."

Sincerely,

Thomas S. Metkus, B.S.

University of Pennsylvania School of Medicine

References

1. Wigton RS and Alguire P. The declining number and variety of procedures done by general internists: a resurvey of members of the American College of Physicians. Ann Intern Med. 2007; 146: 355-60.

2. Barclay S, Todd C, Finlay I et al. Not another questionnaire! Maximizing the response rate, predicting non-response, and assessing non- response bias in postal questionnaire studies of GPs. Fam Pract. 2002; 19: 105-11.

Conflict of Interest:

None declared

Internal medicine: less interventional but not less important
Posted on March 6, 2007
Carlo Pedrolli
S. Chiara Hospital Trento, Italy
Conflict of Interest: None Declared

I think that this paper by Wigton & Alguire gives a right picture of the difference of internal medicine of 1986 and 2006. In general internal medicine there is a lack in some procedures which are now entirely dominium of specialities; only in very small hospital endoscopic procedures are non performed by certified gastroenterologist; the same for cardiologic procedures; what I would like to point out is the very fact that internal medicine is much less an aggressive and operative discipline looking for a charming place in assessment of patients and non interventional procedures (as echography, for example). I would say that that's one of the main characteristic of modern internal medicine; even more internal and even less "interventional". But less interventional doest' mean less important.

Conflict of Interest:

None declared

Procedures and Saving Internal Medicine
Posted on March 9, 2007
Michael A. LaCombe
MaineGeneral Medical Center
Conflict of Interest: None Declared

Has Opportunity's Door been opened a crack by this article and its accompanying editorial? The medical journals have been rife with articles on the death of internal medicine, or the salvaging of it. But no one seems to link its demise to the lack of procedural skills, and attendant income, for general internists. Nor do these two articles go that far. In table 3 of the Wigton/Alguire article, several procedures now performed by U.S. general internists are not listed: echocardiogram interpretation, hemodialysis, bronchoscopy, stress echoes, nuclear stress imaging, sleep studies, and even in a few cases, permanent pacemaker implantation and TEE's. Yet all of these procedures are performed capably by general internists, in Canada. That they are not in the U.S. is not because, as Duffy and Holmboe maintain, general internists feel their patients deserve better. It is because in the main, our residents are never given the opportunity to learn them. Procedures generate income. Procedures pay off burdensome student loans, relieve the pressure to see larger volumes of patients ever more quickly. Procedures add spice to patient care. Patients do not demand that a subspecialist from away do the procedure. Uniformly patients ask: "Why can't you do it?" Cardiology is hardly more fascinating than rheumatology, except for the opportunity for large numbers of procedures, and the income, power, and prestige that brings. Similarly, young people do not gravitate to gastroenterology because of any great magic in the splenic flexure. If the Canadians can do it, so can we. But don't ask permission from subspecialists who control training and credentialing. A greater politic must obtain. Both the ABIM and the ACP have foundations which exist in part to fund research of this type. Both should support impartial clinical research to answer this question posed by the Annals' editorial, "What procedures should internists do?" Take it a step further. Just suppose this research shows that a well- trained general internist can read echocardiograms as well, and more cheaply, than cardiologists. Who else might be interested? Finally, a caveat to you young students out there: if such research is not funded, if this profound question is not answered by funded clinical research, if the question is sent to committee and therefore to certain death, continue to avoid general internal medicine at all costs, as you have been.

Conflict of Interest:

None declared

The more procedures done, the more general internists lose their focus
Posted on March 13, 2007
Edward J Volpintestq
none
Conflict of Interest: None Declared

General internists, like family doctors are poorly paid for their evaluation and management skills. For many, this creates resentment and naturally a desire to increase their incomes.

Clearly, doing procedures can provide for entrepreneurially-directed physicians a solution to this problem. However, human nature being as it is, there is a danger that once the procedure-generated dollars start rolling in, the generalist may change his focus from his cogntive skills to his newly-found and profitable procedural ones. It is too easy to rationalize that doing more and more procedures is providing a valuable service. It can lead to exploitation of patients.

Instrument manufacturers are very aware of generalists' desires for more income and pander to their need. It is not unusual for genealists to receive advertisments for laryngoscopes and dopplers and other procedural hardward for office use with the sales pitich that their use is paid for by insurers and Medicare.

Generalists, particulary those in areas that have a large supply of specialists, should limit themselves to a minimum of in-office procedures. Only the most basic including electrocardiograms, urine analyses, fecal occult blood, rapid strep tests, cerumen removal, etc.

The generalist is a diagostician, a listener, a counselor,a coordinator and a team player. As such, one could say that his or her role is best expressed with a minimum of procedural skills.

Conflict of Interest:

None declared

Super-specialists vis-à-vis Internists in India
Posted on March 16, 2007
Akashdeep Singh
Christian Medical College and Hospital
Conflict of Interest: None Declared

Not only the number and variety of procedures done by internists have decreased but also there knowledge is not at par with the peers in the superspecialities. Some of the reasons for the demise of internal medicine in India are:

First, the present teaching staff in medical colleges consists of honorary doctors, full-time teachers and resident doctors. Honorary professors are very busy with their practices outside the teaching hospital. Students do not feature on their priority list. Full- time senior teachers are very busy in non-academic and administrative work. Students are overlooked by them.1 Second , the number of physicians in the teaching institutes is less than 20% and 80% are in the private practice, who hardly get any time to update there knowledge, procedural skills and practice evidence based medicine. 2 Even those who are in teaching hospitals have limited access to the latest edition of the journals as the institutions are not subscribing the current issues of the journals and there own salaries are peanuts (400- 500 dollars per month) and can't afford the subscribtion of these costly journals. Third, there is also a tendency among the affluent class to directly approach a super-specialist instead of an internist or the family physician. Fourth, with more than 50% seats reserved in medical education based on castism the quality of the doctors in general has detoriated.3 Fifth, the stimulus for superspecialisation is the view that the future of clinical practice lay in super-speciality expertise, and that an internist would lose capacity to manage serious or complex diseases as the knowledge base of clinical medicine continues to expand further the super-specialists is perceived to have better "market value."

REFERENCES

1. Learning and teaching outside the medical colleges. Chetan B. Bhatt Indian Journal of Medical Ethics Jul-Sep1997-5(3)

2. Bhat R 1996. Regulation of the Private Health Sector in India. International Journal of Health Planning and Management 11;253-74

3. The Central Educational Institutions (Reservation In Admission) bill, 2006 rajyasabha.nic.in/legislative/amendbills/hrd/76_2006.pdf (accessed on 15.03.2007)

Decreased access to ER procedures may be linked to fall in IM residency procedures.
Posted on March 19, 2007
Join Y. Luh
University of Texas Health Science Center at San Antonio
Conflict of Interest: None Declared

We read with interest the article by Wigton and Alguire (1) on the declining number and variety of procedures done by general internists. Based on experiences at our own institutions we propose that the notable decline in procedures by internists can be linked to the American Board of Emergency Medicine's (ABEM) move since 1990 to restrict board certification to those who are residency trained in emergency medicine (EM) (2). This has led to an increased number of EM residencies to fill the demand for emergency room (ER) physicians, which has in turn, competed with the access internal medicine (IM) residents have for emergency room experiences during IM residency. EM rotations have traditionally been months where IM residents had more opportunities to perform procedures (central line placement, intubations, lumbar punctures, paracenteses, pulmonary artery catheter placement, and in some institutions, even chest tube placement).

The original survey by Wigton, et. al. (3) was done at a time when physicians trained in IM could still "grandfather" into EM by documenting 7000 hours of full time ER practice, and sit for the ABEM certification exam (2). Those IM residents interested in working in the ER, likely sought out more opportunities to do ER procedures. Many large county hospitals did not have EM residencies and the bulk of ER cases were handled by IM residents and general surgery residents, despite the American Board of Internal Medicine (ABIM) only requiring one month of ER throughout the 3-year residency.

The hospitalist movement, at least in academic practice, has been a route through which some general internists can maintain their procedural skills. However, hospitalists in private practice are often encouraged to consult specialty services such as anesthesia or interventional radiology to perform procedures for central line placement, lumbar punctures, or paracenteses. Most procedures have already been performed by the ER once a patient has been admitted to an inpatient medicine service, thus obviating the need for the hospitalist to do them (A.A. Siddiqi, personal communication, March 16, 2007).

With the replacement of IM residents with EM residents competing for procedures in our nation's emergency rooms, IM residents have lost a major source of procedural experience. Although IM residency training was not designed for a career in EM, we cannot overlook the fact that for many decades before emergency medicine became a recognized specialty in 1979, and for many years after, it was general internists, family practitioners, and general surgeons who were taking care of patients and performing procedures in our emergency rooms.

1. Wigton RS, Alguire P. The Declining Number and Variety of Procedures Done by General Internists: A Resurvey of Members of the American College of Physicians. Ann Intern Med 2007; 146: 355-360.

2. Luh JY, McDill TL, Karnath BM, Freeman DH, Speegle DL, Keeney SE. Physician staffing in emergency departments: results of a Texas survey. Tex Med. 2006 Sep;102(9):52-7.

3. Wigton RS, Nicolas JA, Blank LL. Procedural skills of the general internist. A survey of 2500 physicians. Ann Intern Med. 1989 Dec 15;111(12):1023-34.

Conflict of Interest:

None declared

Procedures in Training and Practice: Are we using the right measure?
Posted on March 22, 2007
Jeanne M. Farnan
University of Chicago
Conflict of Interest: None Declared

We commend Ds. Wigton and Alguire for their impressive and thought- provoking work (1). Whereas their findings certainly signify the evolution of the practice of general internists', we believe that the author's conclusion, that "recommendations and practices for internal medicine residency training in procedures should be reexamined in light of these changes," fuels our growing concerns about procedural training in internal medicine residency. Previously, internal medicine residents were required to demonstrate proficiency in fifteen common procedures (e.g. central line placement, lumbar puncture, thoracentesis, etc.) prior to board certification. Recent changes made to the American Board of Internal Medicine (ABIM) procedural requirements include that resident are required to "safely and competently perform" four procedures, including ACLS, whereas they are only required to "know, understand and explain" the remaining eleven procedures in which they were previously required to demonstrate proficiency (2). We believe these changes do not take into account two major facts about internal medicine residents today.

First, because internal medicine residency continues to include major inpatient clinical responsibilities, residents are still be primarily responsible for performing indicated procedures in a safe and timely manner for their hospitalized patients. This remains especially true during nights and weekends, when attending-led procedural services may not be staffed and patients may require critical diagnostic and therapeutic procedures. Ensuring that residents are able to adequately perform procedures remains critical to ensuring provision of safe patient care at all times. Furthermore, delaying or foregoing procedural training in internal medicine residency invokes the "˜pay-it-forward' phenomenon, in which subspecialty fellowship training programs, notorious for already variable clinical curricula and training requirements(3) may be unprepared to bear the brunt of basic procedural training for their fellows.

Second, the vast majority of internal medicine residents are not choosing to pursue a career as a general internist, while increasing numbers are pursuing hospitalist jobs, either as a temporary position before subspecialty training or as a long-term career(4).In either case, the ability to perform procedures independently remains a necessary skill for hospitalist practice. Not surprisingly, internal medicine residency programs often provide the proof of competence of procedural performance for necessary credentialing and medical staff appointments. For these reasons, the continued reliance on residents at the frontlines of the delivery of hospital care and the growing popularity of hospitalist careers, we encourage re-examining the needs and function of procedural training requirements in internal medicine residency.

References:

1. Wigton RS, Alguire P. The Declining Number and Variety of Procedures done by General Internists A Resurvey of Members of the American College of Physicians. Annals of Internal Medicine. 2007 March;146(5):355-360.

2. Duffy DF, Holmboe ES. What Procedures Should Internists Do? Annals of Internal Medicine. 2007 March; 146(5): 392-393.

3. Whitcomb ME, Walter DL. Research Training in Six Selected Internal Medicine Fellowship Programs. Annals of Internal Medicine. 2000;133:800- 807.

4. Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency programs. Acad Med. 2005;80(5):507-12.

Conflict of Interest:

None declared

In Response
Posted on May 8, 2007
Robert S. Wigton
University of Nebraska Medical Center College of Medicine
Conflict of Interest: None Declared

We appreciate the interest in our study and are pleased it has generated discussion about internists' procedural skills. Farnan and Arora worry that the change in the American Board of Internal Medicine requirements doesn't consider the need for residents to perform procedures competently and safely during training. Resident credentialing is a process for certifying residents who can do procedures independently while in training. Gabriel reviewed this topic and described its use in hospitals in New York state (1). The competency of residents in procedural skills remains am important issue even though medicare requirements for direct supervision have limited the procedures that residents do independently. More information is needed about the procedures done during training by residents and their teachers.

Luh and Karnath propose that one cause of the decline in the number of procedures internists do is that board certification in emergency medicine (EM) is now restricted to those trained in EM residencies. They point out that Internal medicine residents have lost a major source of procedure experience to the EM residents. Our study provides no data on these questions, but we think it is very likely that training opportunities in procedures for internal medicine residents have been lost because of the growth of many specialty oriented residencies and fellowships.

LaCombe suggests the declining popularity of general internal medicine is linked to the decrease in procedures done by general internists and the resulting loss of practice revenue. He contrasts the procedures done in the US with those in Canada and suggests that US internists do fewer procedures because they lack the opportunity to learn them as residents. Bodenheimer and colleagues discuss this idea in their recent paper on the income gap between specialists and primary care physicians (2). They point out that the relative value scale rewards specialists disproportionately because of the number of procedures they do. Would general internists do more procedures if they learned to do more of them in residency and if higher reimbursements made it worth while? This would be a great area for study. Incidentally, according to a recent survey of Canadian internal medicine residency graduates, Canada also has difficulty finding adequate opportunities for learning some procedures in training (3).

Metkus asks whether a non-response bias could account for the differences between the 1986 and the 2004 surveys. Both city size and hospital size affected the number of procedures done in both surveys. The methods used in the two surveys were nearly identical, however, and a breakdown of the respondents and results by city size and hospital size in the 1986 survey (Figure 2) (4) and the 2004 survey (Table 2) (5) shows that not only is the percentage in each subgroup quite similar but also that there is a parallel decline in the number of procedures done within each subgroup. To estimate the maximum potential effect of such a bias, we reanalyzed the 2004 data with the rural sample completely excluded: The mean number of procedures done in practice decreased only from 8.5 to 8.0, still quite a contrast to the 16.0 procedures done in the 1986 survey.

Robert S. Wigton, MD University of Nebraska Medical Center College of Medicine Omaha, NE 68198-4285

Patrick Alguire, MD American College of Physicians, Philadelpha, PA 19106

References

1. Gabryel TF, Brierley MA. Credentialing protocols used by internal medicine residency programs in New York State. Acad Med. 1990 Dec;65(12):769-71.PMID: 2252496

2. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med. 2007 Feb 20;146(4):301-6.PMID: 17310054

3. Card SE, Snell L, O'Brien B. Are Canadian General Internal Medicine training program graduates well prepared for their future careers? BMC Med Educ. 2006 Nov 17;6:56. PMID: 17112385

4. Wigton RS, Nicolas JA, Blank LL: Procedural skills of the general internist. A survey of 2500 physicians. Ann Intern Med. 1989; 111:1023-1034,

5. Wigton RS and Alguire P. The declining number and variety of procedures done by general internists: a resurvey of members of the American College of Physicians. Ann Intern Med. 2007; 146: 355-60.

Conflict of Interest:

None declared

Re: Super-specialists vis-A -vis Internists in India
Posted on May 15, 2007
Neetu singla
AIIMS
Conflict of Interest: None Declared

Dr. Singh has very rightly addressed the reasons for the downfall of the internal medicine in India. The faculty structure in most of the private medical colleges is like a pyramid with a broad base (recently passed out postgraduates with hardly any experience) and a broad head (retired professors with no zeal to do any constructive things).There is no intermediate faculty who have the experience and zeal to work. If you see at the quality work in any field--- research, education , academics, sports every where the native indians are far lacking courtesy ---castism, favouritism, corruption

Conflict of Interest:

None declared

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