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“I am not an internist”

August 2009

Published in the August 2009 issue of Today’s Hospitalist

Earlier this year, someone asked me if I planned to attend the annual American College of Physicians (ACP) conference. I rather flippantly responded that no, I wasn’t attending, because I don’t consider myself an internist. The person I was talking to then asked, “Aren’t you board certified in internal medicine?”

“Yes,” I said, “but so are cardiologists, and I bet not many of them are going either.”

I thought about it afterwards and realized that I had never once attended internal medicine’s big annual event. I even started to wonder if my ACP membership was still current.

And I was perplexed that I had such strong feelings about not identifying myself as an internist. I did train in internal medicine, and I’m extremely proud of the training I received at The Lahey Clinic in Boston. But while I’ve never fulfilled a formal hospital medicine fellowship, I have for the past five years considered myself a hospitalist, not an internist.

The hospital as patient
That wasn’t always the case. After residency, I practiced as a general internist in the Boston suburbs for 13 months. I treated patients in both the office and the hospital, managing my hospitalized patients with the help of many specialists.

I took call every third weekend and every fourth night, and I came through for patients when they needed their Pap smear results or Zoloft prescriptions refilled. And I found being that type of doctor very satisfying.

But that’s not the professional path I’m on now, and as I reflect on my career since, I see very few similarities. I have not, for instance, set foot in a doctor’s office (except as a patient) in more than five years. I can no longer comfortably titrate an SSRI nor can I remember the health maintenance schedule for patients 55 and older.

But the biggest change in my practice is in the patients I treat. Half of those “patients,” or at least half the areas that I spend the lion’s share of my professional time on, aren’t even people “a fact that I would not have been able to comprehend just five years ago. My “patient population” has mushroomed beyond people to include hospital-acquired infections, HCAPS, core measures, resource utilization, length of stay, surgical comanagement, nursing satisfaction scores, multidisciplinary team rounds and hospital administration.

The list goes on. Yes, for between 10 and 12 clinical shifts each month, I care for living patients who have diabetes mellitus, cirrhosis and heart disease, all conditions I learned to treat in my internal medicine training. But the rest of my practice focuses on the hospital as the patient that I need to get well. It is that practice that defines what we are as hospitalists and how we will be able to best position our specialty for the future.

Time to rethink training
It’s true that general internists certainly can understand and even embrace the importance of those issues. But that understanding is very similar to how a general internist views, say, Crohn’s disease.

Yes, a general internist can access both the medications and the general knowledge about treatment options for the disease. But most internists refer these patients to a gastroenterologist. Why? Because gastroenterologists are uniquely trained to care for this patient population.

As a hospitalist, I am likewise uniquely qualified “by the setting in which I practice and by our specialty’s defined core competencies “to treat the symptoms that affect the entire hospital, not just the people in the beds. That’s why hospitalists cannot be considered to be general internists who just happen to practice exclusively in the hospital. It’s the hospital that is our unique patient population. That’s what has transformed our specialty and what distinguishes hospital medicine from general internal medicine.

I have heard the argument that “traditional” specialists qualify as specialists because they complete a formal fellowship. My response is that we need to rethink internal medicine training. I propose keeping the intern year the same as it currently is but then branching off into either an outpatient or a hospitalist track. Having separate tracks would allow each group to specialize, one in outpatient medicine and the other in hospital medicine.

A separate specialty
As Congress moves to mandate better performance from hospitals, the stark differences between hospital medicine and general internal medicine will only emerge more clearly. It will likewise become increasingly clear that a separate specialty in hospital medicine should not only be permitted, but required.

The idea that hospital medicine will eventually be recognized as a separate specialty is, in my view, a done deal. What baffles me is the vast numbers of internal medicine-trained physicians who apparently don’t want hospital medicine to get that formal recognition.

I have heard doctors argue, for example, that insurance companies will not allow internal medicine physicians to practice inpatient medicine if we have a separate specialty. Another argument: Patient care will suffer from increased physician handoffs in the hospital medicine model.

I agree that as a young specialty, we need to improve communication to advance patient safety. But to the argument that internists will no longer be granted hospital privileges, remember that insurers don’t prohibit internists from treating patients with heart disease “or Crohn’s disease, for that matter. Short of a specialized interventional procedure, internists can still treat all the patients who they usually refer to a cardiologist or gastroenterologist.

But there is no defined opposition to these types of specialization. That’s because general internists understand that they cannot be experts in every field and that they must yield to the expertise of other specialists. Emergency medicine and critical care medicine have likewise split off, even though general internists can and do practice these areas of medicine ” and no one argues that these should not be separate specialties.

As medicine continues to redefine itself, specialties “both medical and surgical “will be called upon to partner in the interest of creating a system of care that benefits everyone. We need to be a profession that argues not over who has the right or specialization to care for patients, but who is best qualified to produce high quality, highly efficient patient care.

William T. Ford Jr., MD, is section chief at Temple University Health System in Philadelphia and program director of the Cogent Healthcare hospitalist program there.