What problems will internal medicine face over the next 5 or 10 years

[med2006McGill]

What problems do you think internal medicine will face over the next 5/10 years? Do you guys think the less and less people will want to go into general IM, and more will specialize? Any other suggestions? What about current problems?

Thx!

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[Mumpu]

The biggest problem medicine will face in the next 5/10 (0.5) years can be summarized in three words:

Class of 2006.

 

[orientedtoself]

 

[PickyBicky]

The biggest problem medicine will face in the next 5/10 (0.5) years can be summarized in three words:

Class of 2006.

Ah ha ha ha ha ha ha..... yeah, you know, I've had similar thoughts. July 1 is not that far away. Having invested so much "quality time" in studying for step II and interviewing this year so far, it makes me wonder if I can still perform a credible H&P..... to say nothing about formulating a reasonable management plan. Look out world, 'cause here we come!

-PB

 

[Mumpu]

"Hi, I'm your new doctor. In fact, I'm a new doctor, period. I haven't seen a patient since my sub-internship last August but I can now write for any drug in the hospital formularly without supervision. Why are you clutching your chest?"

 

[durban]

"Hi. I'm your new doctor. Don't I look authoritative and knowledgable in my long, starched white coat and neck-riding stethoscope with the ends hanging symmetrically? These pens, small books in my pockets, and well-coiffed hair round out the picture, don't they? Would you believe I have no idea which diabetic medication to start you on? What a laugh! Of course I do - I have a palm pilot."

 

[Annette]

"Hi, I'm the senior resident overseeing your brand spanking new doctor. Don't worry, I won't let him kill you. Yet."

I think the lack of primary care is going to be a big problem, especially with the pay-for-performance driven reimbursments. Most of my residency class is going to specialize or work as a hospitalist because opening a primary care office just seems incredibly stupid financially. Will medicine morph into FP taking over all outpatient care, and IM taking over all in-patient care?

 

[DoctorSax]

This is my intern--he's going to be putting in your central line.


I think that the most important problems will be (as they has been for quite some time) the insurance system and a health care model that is only beginning to recognize the importance of patient autonomy. Until insurance companies either leave the picture or change how they compensate physicians/hospitals for the prevention and treatment of chronic medical conditions, we will continue to provide inefficient care to patients and focus on the treatment of acute issues. Similarly, patient education is a great buzzword, but it must be re-tooled for 21st century medicine. Patients must be well-informed and empowered to prevent and take care of their chronic diseases--otherwise we perpetuate inefficiency and the classic paternalistic "just take this pill" model.

There was a great NY Times article on diabetes in last weekend's paper--if this link works check it out.

http://www.nytimes.com/2006/01/11/nyregion/nyregionspecial5/11diabetes.html?emc=eta1

DS

 

[rs2006]

Hi everyone
fourth year med student here. Someone mentioned in one of the above posts the idea of "payment for performance." I am a little unclear on what this means and would be grateful if someone here could explain what it is and how it would work. also, would if ONLYaffect IM and Family or would it impact all fields? Any thoughts would be appreciated. thank you very much...

 

[PickyBicky]

"Hi, I'm the senior resident overseeing your brand spanking new doctor. Don't worry, I won't let him kill you. Yet."

I think the lack of primary care is going to be a big problem, especially with the pay-for-performance driven reimbursments. Most of my residency class is going to specialize or work as a hospitalist because opening a primary care office just seems incredibly stupid financially. Will medicine morph into FP taking over all outpatient care, and IM taking over all in-patient care?

I'd be cool with this. Would you?

-PB

 

[BigBadBix]

I'd be cool with this. Would you?

-PB

That would be like a dream come true for me. Can't stand clinic!

 

[Annette]

I'd be cool with it, but I'm not certain it would completely work. Are FP's really equiped to keep a person with CHF, complicated with many other diseases such as DM, HTN, CAD, COPD, etc out of the hospital? Would these patients have to be handled by subspecialists? If so, we need a hell of a lot more subspecialists.

(I know I sound anti-FP, but I don't have a lot to judge FP on. Most of the FP residents I have met are weak in sick patient care, but usually are right on about screening, etc.)

 

[PickyBicky]

That would be like a dream come true for me. Can't stand clinic!

Look, not to be negative here, but seriously..... I've met very few IM bound people who like clinic. All the IM PGY 1-->3 hate it (not all....but many), fellows hate it, everyone hates it! What gives? Is it how we're trained (mostly inpatient), how we're not trained (clinic visits), painfully slow progress Vs. non-compliance with each visist?

-PB

 

[PickyBicky]

That would be like a dream come true for me. Can't stand clinic!

Ah ha ha ha ha ha! Hey, this is coming from a person who wants the ET in place! I have to say, the vent does make pre-rounding alot more efficient.

-PB

 

[BigBadBix]

Look, not to be negative here, but seriously..... I've met very few IM bound people who like clinic. All the IM PGY 1-->3 hate it (not all....but many), fellows hate it, everyone hates it! What gives? Is it how we're trained (mostly inpatient), how we're not trained (clinic visits), painfully slow progress Vs. non-compliance with each visist?

-PB

I agree - very few residents I've met enjoy clinic. I have met some who are really passionate about primary care who look forward to it, but they are few and far between. I wonder if it's partly due to the patient population that comes to most resident clinics. This is a huge generalization, but it seems like they are particularly bad at compliance, communicating with their physician, coming back for follow-up appointments, etc. Also, clinic during residency is typically a huge pain because you have to leave in the middle of a busy day on the wards and trek over to clinic, often to return to the wards later to finish up your work. I think some of these factors can wear on everyone, even residents who would normally like the outpatient setting.

Then there is also the personal preference thing. For instance, I am doing IM because I love complex patients with interesting problems, and I just find the clinic setting to have too much routine care - URI's, back pain, screening, etc. - for my taste. It feels like you have to see hundreds of boring problems for one really interesting case. I also find acute issues more stimulating. I like being able to make an intervention and see the results (or know that it's not working) within hours-days, instead of months-years as in the outpatient setting.

Funny thing is, I was trying to explain this during a recent interview with the director of a primary care track, and she kept telling me I sounded like an outpatient person! How she got that impression I will never know...I guess people hear what they want to hear.

 

[BigBadBix]

Ah ha ha ha ha ha! Hey, this is coming from a person who wants the ET in place! I have to say, the vent does make pre-rounding alot more efficient.

-PB

Ah yes, the ease of seeing a patients when they can neither talk nor move of their own free will is truly wonderful. Just one of many reasons why the ICU is the best place in the hospital!

 

[Mumpu]

Why clinic sucks for IM? Simple! Like BBB said, people go into IM because they like to think. Even considering the (ahem) complexity of an average clinic patient, you have 10 minutes tops to do your stuff. Not much time to think, is there? Besides, it sucks hugely to have your life totally dependent on patients who are unable to show up on time or who come with 20 problems for a 10 minute visit. Don't you love the 4 pm Friday patient who waddles in at 4:30? And then you have to dictate the 25 patients you saw that day. Ugh. Aside from calls, my inpatient ward days were much shorter than clinic days and with a much better lifestyle (free time to walk around, socialize with people, eat).

I consider hospitalist medicine to be a primary care field, except in the hospital setting. You can take care of all the same problems you see in clinic but in an interesting, complex patient that you can be thorough with and not feel like you are doing Step 2 CS all day every day.

 

[DoctorSax]

Why clinic sucks for IM? Simple! Like BBB said, people go into IM because they like to think. Even considering the (ahem) complexity of an average clinic patient, you have 10 minutes tops to do your stuff. Not much time to think, is there? Besides, it sucks hugely to have your life totally dependent on patients who are unable to show up on time or who come with 20 problems for a 10 minute visit. Don't you love the 4 pm Friday patient who waddles in at 4:30? And then you have to dictate the 25 patients you saw that day. Ugh. Aside from calls, my inpatient ward days were much shorter than clinic days and with a much better lifestyle (free time to walk around, socialize with people, eat).

I consider hospitalist medicine to be a primary care field, except in the hospital setting. You can take care of all the same problems you see in clinic but in an interesting, complex patient that you can be thorough with and not feel like you are doing Step 2 CS all day every day.

I guess this is all fascinating to me because I chose IM for the intellectual challenge, but also for the continuity. While progressing through the clinical years, I've become convinced that the hospital is a terrible place to deliver primary health care. Not only is it an expensive and inefficient way to take care of people, but it turns people into "hits" and depersonalizes the doctor-patient relationship. "Hi, we just met and I want you out of here as soon as possible to "diurese my census," but don't worry, I'll still deliver competent and compassionate care." Too Foucault!

This is not to say that the hospital is useless--hospital medicine is amazing because it concentrates all the resources in one place. Complex patients with acute problems should only be taken care of in a hospital--ICU patients, trauma, emergency exacerbations of chronic disease, etc. But we have all been on service when half the patients should be there and half should not. To me, that's a system failure, but maybe I'm crazy.

And how many people come in for problems that could have been prevented with proper preventive care? It's for sure that IM folks are needed to manage hospital patients, but we are also needed in the outpatient setting to manage patients with a complex array of problems and prevent them from getting to the hospital in the first place. I know that our reimbursement system is crap, but I'm pretty sure that most of us didn't go into IM for the bling bling. As for the 10 minute rule, I've seen clinics where IM docs see 30-40 patients a day, and I've seen others where they see 5-10. Lots of variability and depends on where you practice and how you structure it.

I guess that in the end clinic can be frustrating, but maybe that's residency--I assume it gets better when you're out of training because I don't hear many IM clinicians kvetching about their clinics.

DS

 

[Mumpu]

A lot of good points Sax!

There are certainly many people in IM who hate the hospital, and subspecialties with the exceptions of critical care and hospitalist are outpatient-based. Which makes me happy because someone doing a clinic is me not doing one.

 

[DoctorSax]

A lot of good points Sax!

There are certainly many people in IM who hate the hospital, and subspecialties with the exceptions of critical care and hospitalist are outpatient-based. Which makes me happy because someone doing a clinic is me not doing one.

I agree, bro. I just think that we're poorly trained for the outpatient stuff, as PickyBicky pointed out above. That's why I've started to look at primary care tracks!

DS

 

[u_r_my_serenity]

This will be me in June:

"Hi, I'm your new doc... oh my God, this man needs a doctor..."

 

[rs2006]

From what I heard on the interview trail, it seems like the only issues medicine will face will be those having to deal with the aging population-- how medicare is impacted by the rapidly aging baby boomer generation that will start to turn 65 in approx 5 years-- how is medicare going to deal with this huge glut of people given the fact that it can barely handle its current load (Most physicians would that medicare reimbursements (in all fields) in ALL FIELDS are lowsy, but are particularly bad in medicine. However, I do think that medicine is in for a "perfect storm" as fewer people are going into it as most US Grads are running for so called "lifestyle" specialties that offer excellent pay such as rads, anesthesia, ophtho, and derm. In my class approx 25% of my class is running for anesthesia and another 10-15% for rads. Given these facts, there is bound to be a shortage at some point in the future and that salaries should go up (assuming that this shortage of providers is handled the same way it has been in anesthesia-- namely that the salaries go up). But on the other hand, I fear that this may not happen as the way medicine (IM) is billed for is that it is billed as an office visit, NOT a procedure as anesthesia or however rads is billed. I welcome any dissenting or differing posts as always. Just my 2 cents.

 

[sophiejane]

I'd be cool with it, but I'm not certain it would completely work. Are FP's really equiped to keep a person with CHF, complicated with many other diseases such as DM, HTN, CAD, COPD, etc out of the hospital? Would these patients have to be handled by subspecialists? If so, we need a hell of a lot more subspecialists.

(I know I sound anti-FP, but I don't have a lot to judge FP on. Most of the FP residents I have met are weak in sick patient care, but usually are right on about screening, etc.)

It depends entirely on the FP and where they trained. Some FP programs turn out docs with inpatient management skills that rival those of IM docs, because they have almost as many hours in general IM as the IM residents--this is particularly true with unopposed FP programs in urban areas. What they don't get as much of is outpatient general IM and outpatient IM subspecialties.

If you trained somewhere that had an FP and an IM program at the same hospital, I can see where you would get that impression, and it was probably true, because FP residents at most opposed programs are the red-headed step children...

I think it's a noble and attainable goal for FPs to start really managing the sicker patients and keep them out of the hospital. But we have to change the way FPs are trained if this is ever going to happen. You can't be fighting IM residents for the sicker patients and procedures and expect to be competent at managing IM-type patients when you're done with residency...

 

[deleted87716]

Are FP's really equiped to keep a person with CHF, complicated with many other diseases such as DM, HTN, CAD, COPD, etc out of the hospital?

Well-equipped, in fact. You just described most of my patients.