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Health Care System Chaos Should Spur Innovation: Summary of a Report of the Society of General Internal Medicine Task Force on the Domain of General Internal Medicine

Eric B. Larson, MD, MPH, the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine*
[+] Article, Author, and Disclosure Information

From the Group Health Cooperative, Center for Health Studies, Seattle, Washington.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Eric B. Larson, MD, MPH, Group Health Cooperative, Center for Health Studies, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101-1448; e-mail, Larson.e@ghc.org.

Ann Intern Med. 2004;140(8):639-643. doi:10.7326/0003-4819-140-8-200404200-00011
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The Society of General Internal Medicine asked a task force to redefine the domain of general internal medicine. The Society believes that the chaos and dysfunction that characterize today's medical care and the challenges facing general internal medicine should spur innovation. The task force proposed the following recommendations. 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 given by their teams, embrace changes in information systems, and aim to provide most of the care required by their patients. 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 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 in generalist fields. Research should 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. The task force believes that these changes will benefit patients and the public and reenergize general internal medicine.

*For a list of the members of the Society of General Internal Medicine Task Force on the Domain of General Internal Medicine, see the Appendix.





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A Perspective from Trainees
Posted on April 28, 2004
Vineet Arora
University of Chicago
Conflict of Interest: None Declared

We applaud Dr. Larson and the SGIM Task Force on the Domain of Internal Medicine on their report which highlights several key problems with the training of future general internists. However, at a recent meeting of the ACP Council of Associates, our group, composed of trainees in internal medicine, expressed concern over several issues that remain unaddressed.

First, the addition of a fourth or "mastery" year for general internal medicine training without a substantial discussion of the current financial pressures facing trainees is potentially harmful to future interest in this field. Given escalating student debt, increasing the length of training for a field perceived to be underpaid could have devastating consequences for any student interested in general internal medicine. Although the authors make reference to reimbursement reform, it is doubtful that these changes will address the effect of increasing debt on student specialty choice in a timely fashion.

Also, although the authors suggest that training reform will lead to a proper balance of outpatient, inpatient and subspecialty experiences in the first two years in order for trainees to make informed career decisions, we are skeptical that this can be accomplished. Given the degree of financial dependence that teaching hospitals have on housestaff for provision of inpatient care, major changes in healthcare delivery would be required to facilitate this reform.

While we agree training reforms are necessary to prepare future internists for their practice environment, we are concerned about the lack of trainee representation on the SGIM Task Force. The challenges that we face today are different from those of our mentors and teachers. In addition, current practice models of internal medicine include hospital medicine and subspecialty practice. To ensure that these concerns are addressed, it is crucial that all parties be included in this conversation.

Conflict of Interest:

None declared

A time for leadership and involvement
Posted on May 20, 2004
Joseph W. Humphry
Universtiy of Hawaii
Conflict of Interest: None Declared

The article by E. Larson summarizing the SGIM Task Force on the Domain of General Medicine and the accompanying editorials are timely and well written bring to all of us the precarious position of primary care in the dynamic health care system. The Task Force report and contributing authors fails to recognize both opportunities and system changes that are essential in improving health care in the United States and defining the role of primary care the future system. The recognition of the need for a fundamental change in the method of reimbursement is central in improving the system and aligning patient, providers and payers. Cost will be a major factor in driving system changes and will requiring primary care to relinquish certain traditional roles to less expensive team members. The very foundation of the doctor-patient relationship needs to give way to building a broader understanding of an integrated delivery system that retains the critical trusting relationship with the patient. The physician may not be the team member that retains that primary relationship.

Physician's training focuses on curing, not caring. Hospital centered training fails to prepare physicians for caring for patients with chronic conditions and this role may not make effective use of our skills. The inability to consistently care for patients with chronic conditions has lead to initially pharmaceutical supported and now health plan funded disease management programs. These programs come in various forms that directly engage the patient providing education, case management and systematic population data collection and brand identification with the health plan. The evolution of disease management is a further indictment of the failure of primary care in managing chronic conditions. Disease management builds the relationship with the sponsoring organization.

As primary care defines their core values and competencies, health plans and policies are pushing for major changes. There needs to be a much more pro-active movement on the part of primary care if they are truly going to have a seat at the table. This opinion is based on the following observations:

The Chronic Disease Model needs to be central to defining primary care and requires a team approach. The system needs to pay for the team and not fragmented pay for team members. How would a basketball team function if each member was paid by the number of points scored? Nurse managed team care model has been the intervention arm for the majority of population based interventional trails with primary care being the placebo arm. Those studies consistently should the effectiveness of nurse delivered chronic care based on protocol, a simple technique to improve management that primary care has never adopted. More recently, specialty teams in diabetes and anticoagulation show better quality less expensive outcomes than primary care practice.

Physicians should not be involved in running their own office. The single physician and small group practice has no role in an efficient or effective system. Improved quality requires the rapid adoption of new information systems. Primary care physicians need to be in the forefront of embraces this technology that focuses on improved care. The resources for the technology are out of reach for a cottage industry. Central to this change is to promote the patient owned record and population based quality improvement information systems that go beyond the traditional EMR. , , These systems will primarily use web based technology.

Primary care needs to be proactive in engaging payers in pay for performance reimbursement. Pay for performance requires a fundamental change in the quality of reporting (coding) both diagnosis and procedures. Primary care must abandon CPT coding and support ICD-10 coding for both diagnosis and procedures as it is implemented over the next several years. These systems for shifting compensation are rapidly evolving often with little input or knowledge from organized medicine.

Physicians, in general, must be concerned for the cost of medication and the marketing practices of the pharmaceutical companies. They must furthermore address major issues of the huge administrative cost of medical care and the totally irrational number of health plans and payment systems. This concern must extend to the uninsured and the recent rapid expansion of the "safety net" to assist the uninsured and underinsured. We build more system rather than fix the systems that we have. If primary care physicians do not directly support a single payer system, they must at least support a uniform system and standardized policies.

Health care is a "rudderless vessel". Primary care needs to seize the opportunity to bring about the system changes required to improve care and control costs. This requires leadership that goes beyond defining core competency and building consensus. It will also require many who are retreating or surviving to support, re-think and re-tool. The United States clearly has the financial resources to have the best care in the world. The challenge is now to find the human resources to redirect the ship.

The opinions expressed in this letter are my own and does not reflect the opinions of any of my employers.

Conflict of Interest:

None declared

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