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February 13, 2008
Another slice of internal medicine: comprehensivist?

We all know that ambulatory medicine, that subfield of internal medicine, is hurting.

That's the case for a number of reasons. Given the current practice environment, many physicians no longer find outpatient practice to be rewarding. When you couple falling reimbursement with a proportional increase in paperwork hassles and other frustrations, you've created what ACP and ABIM have proclaimed the “perfect storm” that has led to the decline of the office-based internist.

Recent estimates demonstrate that 21% of internal-medicine-only trained physicians are no longer in practice after 10 years. Equally troubling, ACP numbers show that the number of third-year residents planning a career in internal medicine has dropped from 54% in 1998 to 27% in 2003.

In response, the ABIM has proposed a maintenance-of-certification process for the office-based physician. Such a comprehensive care physician (or "comprehensivist") would be, among other things (and I'm quoting from an ABIM committee report), an

• expert diagnostician and clinician
• a patient advocate
• an effective communicator
• a team leader and effective teammate
• an effective change agent
• a practitioner accountable for efficient, accessible care

Last time I checked, this was the job description of, well, a doctor. The ABIM claims to have many tools available to validate a physician’s efficacy in the aforementioned skills (because what, really, did we learn during all those years of medical school and residency?). Once certified, physicians would be able to claim that they practice “Internal Medicine with [a] focused practice in Comprehensive Care.”

Now, I don’t claim to know how to cure the particular maladies of outpatient medicine, but I’m willing to bet that the aforementioned recertification process won’t do it! What would it mean to be a physician who did not strive to be a patient advocate and an expert diagnostician and clinician? (Unemployed, I’d guess.) We have always differentiated our skills by subspecializing in internal medicine, surgery or obstetrics. But across the board, we share a passion for our patients and a desire to provide efficient, effective care.

The ABIM claims that the physicians who would seek such designation should focus their practice “on providing longitudinal, coordinated care for patients across the continuum of illness and sites of care.” Who would practice outpatient medicine, or any form of medicine for that matter, in any other fashion? Would non-comprehensivists intentionally practice uncoordinated and discontinuous care? Perhaps these doctors would shun medical charts and follow-up labs, and have office hours only on the third Tuesday of monosyllabic months.

I am also trying to picture the validation tools that the ABIM claims to have already developed to assess a comprehensivist’s competency. Will the team leadership test require proof that a physician’s fantasy football team made the playoffs last year?

And what about proving one’s merit as an agent of change? I am not even sure what this means, but it sounds like the campaign slogan for any one of the current slate of presidential candidates vying for our vote.

Unless there is a lucrative procedure attached to this added recertification, and I have great difficulty envisioning what such a procedure would entail, it is unlikely to staunch the ongoing mass exodus of primary care physicians from office-based practice.

As a hospitalist trained in internal medicine and a long-standing member of ACP, I am certainly sympathetic to the plight of office-based medicine and to any attempt to address that plight. I also believe that our medical leaders need to be thinking outside of the box in terms of solutions.

While comprehensive care recertification may be the quid quo pro for hospitalists' "focused recognition" recertification, I don’t think the “comprehensivist” represents the much needed lifeline for ambulatory care. I see that I am not alone in this opinion: Last month, ACP also came out against the idea.
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4 Comment(s)

Thomas Bolte wrote:
Greetings Dr DeLue,
My practice has grown into a specialty where I attract patients with symptoms that defy diagnosis.

Physicians refer patients to me whose symptoms are being masked by pharmaceuticals, due to an inability to identify a cause for the symptom(s). I enjoy solving medical mysteries and improving a patient's quality of life, and have expanded my medical knowledge base in many areas in order to solve them.

I have many interests outside of medicine as well, which help the communication process between a patient and myself, and often provide clues that lead to solving an evasive diagnostic mystery. This is what I call "comprehensive medicine" and it's why I call myself a "comprehensivist." Perhaps it's also being a "medical detective," though aren't we all?

Most Internists and general practitioners are not interested in pushing beyond the paradigms set forth by modern medicine, which hold a diagnostician within the realm of pharmaceutical solutions. Most physicians have no training in diet and nutrition, nor do they take the time to explore a patient's eating habits, social habits, nutritional supplements and so on.

So I consider a "comprehensivist" to be a physician who goes more than the extra mile to bring a patient's state of health back to that of wellness, someone who relies on pharmaceuticals only when absolutely necessary. Such a physician has increased his knowledge of medicine further than what is required to run the "average" medical practice. I don't think all physicians are "comprehensivists," though they should be...

--Dr Thomas Bolte, NYC Internist and Comprehensivist
Manhattan, NY | Tue, Apr 15 2008 08:41 AM

Erik DeLue wrote:
Dr. Bolte,

Thank you for your comments. My point exactly, a "comprehensivist" will never be a designation that can be bestowed upon a physician by the ABIM. It is, as you describe, a physician who treats the whole person, not just their disease process.
Mt. Holly, NJ | Wed, Apr 16 2008 09:26 AM

Carolyn Rees wrote:
It's a better description of what I do than PCP. People think primary care is medicine's equivalent of primary school.
Caldwell, Idaho | Fri, May 7 2010 06:35 AM

Erik DeLue wrote:
Dr. Rees, Thanks for your comments. I agree PCP is not a great name. Anytime your name is also shorthand for an illicit drug, nothing good will come of it.

In all seriousness, if there is a way to adequately convey in a title the hard work and dedication most primary care doctors exhibit, I say change tomorrow. Let me make a suggestion: Superheroists.
Mt. Holly, NJ | Fri, May 7 2010 10:58 AM

CHECK OUT RECENT POSTS

About Erik DeLue, MD
Erik DeLue, MD, examines the challenges of running and reinventing a hospitalist program. He is medical director of the hospitalist program at Virtua Memorial, a hospital in Mt. Holly, N.J.

This is the third community hospital program that Dr. DeLue has worked for in his nine years as a hospitalist. Join in the dialogue on issues that range from compensation and 24/7 scheduling to how to work with competing hospitalist groups.

The opinions expressed by Dr. DeLue are his own and do not necessary reflect the opinions of his employer or Today's Hospitalist.
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