Primary Care Internal Medicine is Dead—Long Live Primary Care Internal Medicine

At the dawn of modern primary care in the early 1970s, many of us interested in the field as a career viewed internal medicine as the ideal specialty for its training and practice. We admired internal medicine’s breadth, depth, and intellectual rigor. Its comprehensive, personalized approach to care dovetailed nicely with primary care’s mission of first contact responsibility and establishment of long-term trusting relationships. Student interest coupled with academic internal medicine’s recognition of primary care’s future importance led to pioneering residency training programs.¹ Twenty-five years later, most academic medical centers were heavily engaged in the training of primary care general internists—54% of 3rd-year internal medicine residents indicated on the 1998 In-Training Exam that they planned to practice primary care.²

However, the bloom began to come off the primary care rose as advancing corporatization of medicine promoted the commoditization of primary care and the deprofessionalization of its physicians. The terms “gate keeper” and “primary care provider” entered the daily lexicon. At the same time, specialty-dominated payment advisory bodies such as the American Medical Association’s RBRVS Update Committee assigned low-value reimbursement scores to primary care services,³ precipitating rushed office visits to meet “productivity” quotas. The term “hamster wheel” emerged to describe the primary care practice environment, which further eroded under the pressure of demoralizing increases in administrative tasks. Not surprisingly, the attractiveness of a career in primary care internal medicine rapidly faded. In less than 10 years, the proportion of trainees planning to practice primary care fell by over 50%—hospitalist medicine began to look much more attractive to those interested in a generalist career.² Primary care internal medicine tracks began to cut back and currently offer just 425 internship positions,⁴ far below projected needs.

Helping to fill the void are family physicians and advanced clinical practitioners (ACPs—nurse practitioners and physician assistants). Family medicine has grown as a major primary care specialty, but it too is having problems attracting trainees.⁴ ACPs represent an important avenue to closing the primary care workforce gap, being designated as “providers” by Medicare, granted independent practice privileges in many states, and awarded high marks for screening, prevention, and chronic care management.⁵ However, concern has arisen about decision-making performance when working solo in high-stakes situations.⁶

With access to well-structured primary care being a key determinant of health outcomes,⁷ is there a meaningful contribution to primary care that general internists can make despite their dwindling numbers—a contribution that might also improve the attractiveness of the field? Outlined here are two suggested models of primary care internal medicine practice, one resembling the original consultative role of the internist during the era of community general practice and the other featuring the primary care general internist as an apex clinician in a multidisciplinary primary care practice. Both represent team-based approaches to expanding access to high-performance primary care.

The first is a back-to-the-future model. In the early decades of internal medicine, before the advent of specialty certification, the community-based general internist served as a consultant to local general practitioners. Tasks included giving curbside consultative advice, seeing referrals, and assuming ongoing care of complex patients. The community internist was a true practicing generalist, serving as a valued resource with in-depth knowledge across the spectrum of adult medicine, sometimes supplemented by expertise in a particular area. A proposed modern version of this classic model would have the general internist serve as the initial go-to consultant for independently practicing ACPs in high-stakes, high-uncertainty situations, especially in rural and other underserved areas where physicians’ presence is limited. In such situations, the frontline independently practicing ACP would be invited (or assigned) to consult the community or regional general internist instead of immediately resorting to high-cost imaging, ER referral, or specialty consultation. Some family physicians might also want to take advantage of this service. The consultation could be performed as a brief telephone or video conversation, e-consult, telemedicine visit, or full in-office evaluation. In areas that are medically underserved, one might designate a small group of general internists as the frontline consultants. The value proposition should be measurable in terms of access to physician care, diagnostic accuracy, cost-effectiveness, efficiency, and patient satisfaction. Reductions in avoidable ER visits, unnecessary imaging, and premature specialty referrals would be expected; those specialty referrals which do result should be more precise and more fully worked-up, facilitating specialty care.

General internists taking on this role might do so on a part-time basis, reserving time for maintaining a team-supported, reduced-size patient panel, including patients with complex problems referred to them by community practitioners. Hospitalists might consider such a role as a welcome complement to their inpatient work and an opportunity for a hybrid career. Categorical residency programs in internal medicine could train large numbers for this role by offering intensive, supervised clinical experiences in consulting to frontline solo primary care practitioners. The training would focus on the development of consultative skills and the learning of practical, evidence-based approaches to complex primary care problems.

A second proposed model places the general internist as the “apex clinician” in a multidisciplinary advanced primary care practice. In this model, the general internist would serve as an on-site consultant to the practice’s other primary care clinicians and team members. This individual would be the go-to person for workup and/or ongoing care of patients with complex acute or chronic medical problems. This model removes the general internist from the burden of caring for a large panel of patients—many of whom can be perfectly well managed by other members of the primary care team. Instead, it focuses effort on addressing high-stakes situations requiring in-depth knowledge. It skirts the potentially contentious issue of team administrative leadership by simply designating to whom diagnostic and management challenges should be directed. Residency training for this role would be best served by primary care internal medicine tracks embedding residents in well-structured advanced primary care practices. Team-based care and frontline workup and management of patients with complex problems would dominate the learning agenda.

These models depend upon a multidisciplinary approach to primary care practice, where sustainability and optimal patient outcomes derive from all team members operating at the peak of their certification.⁷ Doing so will enable primary care general internists to focus on those aspects of care to which they can uniquely contribute—a key determinant of professional satisfaction.

Transitioning from the currently unsustainable state of primary care internal medicine practice to one of the proposed models will require important changes in training, workforce, and payment. The development of interdisciplinary teamwork competencies will need to become a priority, starting in medical school and intensifying during residency. Necessary workforce changes involve recruiting more ACPs to primary care practices as key members of a multidisciplinary team. While independent ACP practice might be necessary in medically underserved areas, multidisciplinary team-based care produces the best outcomes⁷ and should be encouraged as much as possible. As for payment reform, the National Academy of Medicine has recently concluded that team-based primary care requires largely supplanting inadequate fee-for-service reimbursement with prospective payment and net investment.⁷

These models of primary care internal medicine practice aim to enhance patient outcomes and raise the professional status and satisfaction of the primary care general internist. The practice of primary care general internal medicine had been one of the best jobs in medicine. It’s time for its renaissance. Long live primary care internal medicine!

Funding

This study is funded by support from the Joseph and Kathy O’Donnell Family Foundation.

Declarations

Conflict of Interest

The author reports no conflicts of interest.