DB'S MEDICAL RANTS

Internal medicine, American health care, and especially medical education

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The hidden curriculum – not just in med schools

For many years I have advised against internists using the term primary care.  Internists have always cared for patients of great complexity with skill and humanity.  Until recently all internists did both outpatient and inpatient care.  More recently the growth of hospital medicine has convinced many internists to forgo inpatient medicine.

Primary care became a hot term in the 1980s.  Unfortunately the term underwent semantic drift and now seems to mean “simple care” to many physicians – both in and out of medical schools.  What internists do is not simple care.  However, I continue to get comments suggesting that primary care does not need physicians.

Any debate must hinge on a careful definition of terms.  This debate suffers from a lack of understanding of the complexity of continuous, comprehensive, complex care that internists provide for their patients.

Dr. Dave wrote this wonderful paragraph:

I am currently a hospitalist but did primary care for 12 years before joining the ranks of hospitalists. Although hospitalized patients are sicker, I found outpatient medicine to be much harder and more challenging. It also didn’t last for a shift – someone has to cover the practice at night and it usually isn’t an NP. Whoever out there thinks that outpatient care can be reduced to plugging people into algorithms is ignorant of the nuances of humanity and our varying responses to diseases and treatment.

However, medical students and residents must face a hidden curriculum both in medical schools and in community hospitals.  They face a continuous degradation of outpatient internal medicine (and even more family medicine).  Our payment “system” also degrades outpatient medicine.

If we cannot change the culture of medicine, then we will have inadequate outpatient care for our patients.  The job needs more prestige than it currently receives.  The job needs a better understanding from payers.  We need to better understand the limits on the job.

Some critics want to just blame the medical schools for our primary care shortage.  While the medical schools are not innocent, they are not the primary guilty party.  We have many defendants in the court of hidden curriculum.  Some of the defendants write comments on this blog.

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