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.