Whither the Generalist?

Panda Bear, MD had a very interesting post on primary care medicine up on his blog recently. He is currently an EM Resident after spending a frustrating year training to be a Family Practitioner. He also brings his characteristic USMC sense to the subject of chiropractic 'medicine', but I will not comment on that here except to say that I agree with him.

Something terrible has happened to internal medicine and family practice in the past decade. Traditionally, internal medicine was considered to be "adult medicine" and family practice physicians had, as the name implies, mastered a broader knowledge base including pediatrics and Ob-Gyn. Necessarily, they sacrificed some detail for the sake of a broader base. In that regard, they were, arguably, the forerunners of the Emergency Physician. I used to explain what I do to by telling people I would be "like a family practitioner specializing in emergencies".

Twenty years ago, when I was a medical student (and then a resident) the internists were jumping over each other to get procedures, to put in central lines, and to run codes. Their training was rigorous and I decided against internal medicine because of the level of detailed knowledge required. I liked the immediate gratification of procedures and emergency care but I didn't care a lick for long-term management. I knew that the fine points needed someone with more focus than I could produce consistently. Also, general internists, twenty years ago, only called in the specialists, well, for special cases. They ran codes and managed patients in the ICU and did it well.

I have always viewed internists, especially the ones I trained under at medical school, as upholding the best traditions of medicine. Within their ranks were some of the most brilliant people I've ever met, doctors who emanated knowledge and compassion and who taught me, well, that I shouldn't be an internist.

However, since the specialty of Emergency Medicine has become a prominent player in almost all major hospitals, the internists and generalists have stopped taking care of critically ill patients. They have also stopped taking care of "unstable" patients. They only care for patients after they have been "stabilized", usually by a combination of EMS and Emergency Physicians and Nurses. Or, they take patients in transfer from the ICU or SICU where an 'intensivist', usually a pulmonary/critical care specialist, has directed their care.

So what do the general internists and family practice docs do these days? They manage chronic diseases like diabetes and hypertension, they provide early diagnosis of many conditions with insidious onset such as cancer, arthritis, and lymphoma . In smaller communities they may still do some orhtopedics, some psychiatry, and, in fact, the whole range of non-surgical care. I'm sure that some family practitioners still (foolishly given the malpractice climate), deliver babies.

Most generalists have been forced to employ midlevel providers (Physician Assistants and Nurse Practitioners) to see enough patients to make enough money to make any money. Many times, they don't really see patients anymore but merely provide oversight.

Now, what happens if you have chest pain? If you go to your general internist's office and he or she finds out you have risk factors for cardiac disease and are over 30 you will likely find yourself in an ambulance on your way to see me. If you call the nurse "answer line" they will tell you to go to the "nearest emergency department". Or, you may choose to come directly to me.

What if you need quick lab results? What if you have vomited yourself into dehydration and need an IV? Go to the ED.

What if you have abdominal pain and call your physician or even your surgeon if you have one? They will tell you to come to the E.D. for evaluation. After all, where else can you get a STAT CT scan? Is there still a surgeon in the United States that will take a patient to the operating room based on a clinical exam and patient history?

If you call the nurse line you will get the same response. Or, you can eliminate the middle-man and just come on in. Bonk on the head. E.D. Laceration? E.D. Vomiting blood? E.D. Medication adjustment? Call your internist for a follow-up three or four weeks from now or come on in.

I am not happy about this situation and I am not criticizing internists or family practitioners in that I do not think that this was planned or desired. I think that internists know more about medicine than I ever will or care to, but what are they going to be doing ten years from now? We have made it easy for them to opt out of high liability care and they have opted.

The reality of it has been striking especially since, at our facility, our hopsitalists (internists who confine themselves to hospital practice) have begun demanding 'complete workups' prior to admitting a patient from the E.D. Rather than taking Mr. Smith, with unstable angina, directly upstairs after initial stabilization in the ED, they now won't take him without all his tests being complete including his CT of the chest and his horizontal stool-velocity. If a test is pending when a patient is sent upstairs I am sure to hear about it as an 'incomplete workup'. Well damn!

When the E.D. is popping and the E.M.S. crews are bumping into themselves in the ambulance bay the best thing I can do for everyone is to stabilize and move the patients. If it's not so bad then I always complete my workups and always review the patient's prior admissions. But not accepting an admission because the diagnosis is in doubt or the workup is partial? I mean I know there's lots of paperwork to do but to call me upstairs to do a lumbar puncture on a patient admitted three days ago? Can you really not do one? Didn't you do them in medical school? Internship? Residency?

By insisting on this level of completeness from me the hospitalists, internists, and many surgeons have aced themselves out of caring for the critically ill and are losing their clinical judgement and skills for lack of use. In the meantime my skill and knowledge base is increasing. Hell, internists in my town don't even manage the sorta-ill or the kinda-ill anymore. Like most things in life, true gut-knowledge comes through repetition. If you haven't run a code in three years then I understand why you don't want to run one today. I don't know why they don't see this but they don't. Job security for me? Sure. But I'd rather do Emergency Medicine.