The debate continues – A primary care doctor by any other name …

Bob Doherty is a great guy (except for this Mets thing).  He and I have discussed this issue several times.  As his article makes clear, he hangs on to the moniker for political reasons.  Bob lives in a political world, and he believes that politicians “get” primary care.

I can understand the desire to shed the words “primary care”, but I think this would be unwise at a time when politicians and policymakers alike seem to buy into the idea that “primary care” is the keystone of a high performing health care system, as Senate Finance Chair Max Baucus (D-MT) has famously described it. Whether legislators will do enough to live up to primary care’s billing as the “something on which other associated things depend” is still to be determined.

As the ACP solutions paper defines primary care, we should champion it:

“General internists provide long-term, comprehensive care in the office and the hospital, managing both common and complex illnesses of adolescents, adults, and the elderly. Internists receive in-depth training in the diagnosis and treatment of conditions that affect all organ systems. General internists are specially trained to solve puzzling diagnostic problems and can handle severe chronic illnesses and situations where several different illnesses may strike at the same time. They are also trained in the essentials of primary care internal medicine, which incorporates an understanding of disease prevention, wellness, substance abuse, and mental health. Internists’ training is solely directed to care of adult patients; consequently, internists are especially focused on the care of adult and elderly patients with multiple complex chronic diseases.”

I live in an educational world of medical students and residents.  When they hear primary care, they hear overworked, underappreciated and little or no access to inpatient medicine.  We could have a long blog debate on how and why the growth of the hospitalist movement has made the classic general internist an endangered species.

I love general internal medicine.  I love attacking a variety of undifferentiated problems.  I would be bored focusing mostly on chest pain, COPD or dialysis.  Complex patients are fascinating.

If I were graduating from residency today, I would likely become a hospitalist, because outpatient practice alone would not meet my internal conception of the physician that I strive to be.  Most students choose internal medicine because of the inpatient experience.

Prior to my 3rd year in med school I had no idea what I would become.  My first week on the internal medicine rotation (November 1973) convinced me that I was an internist.  I loved and still love ward rounds.  Inpatient medicine provides me the opportunity to be a detective and a comforter.  This week on rounds we had several challenging diagnostic and therapeutic puzzles.  We also diagnosed severe depression and participated in end of life care.  We used our entire brains – both right and left.

Having done outpatient medicine for a bit over 20 years, I know that outpatient medicine has the most interesting diagnostic dilemmas, but they occur less frequently.  I know the joy of the physician side of a long term physician patient relationship, and I miss it.

For years I have objectied to the dichotomization of general internal medicine.  I have blogged about the problems of some hospitalist situations.  Most outpatient only general internal medicine situations are even more problematic.

Fortunately, I know some great internists who still do both.  They have the best jobs.  But their ability to succeed in those jobs is becoming threatened. And few graduates see that job as a desirable one.

So I applaud Bob Doherty for his clear explication.  I applaud the political struggle that internal medicine is fighting, but I worry about how we make that job attractive to residents.  Perhaps the patient centered medical home is the answer, it just might be.

The term primary care works in the halls of the Capital, but it fails in the minds of students and residents.  We will probably continue to debate this for several years.  Our debate clearly is shaped by the differing context of our daily lives.