Dr Bob posts on DB's Medical Rants an interesting reference to his paper in Journal of General Internal Medicine. Family physicians feel your pain, man … and I agree with you that there remains a place for General Internal Medicine … but … here's what may be an odd concept: the General Internist as specialist in complex adult medicine .. just as the pediatrician could be positioned as a specialist in complex pediatric medicine.
Ever Since Family Medicine displaced "General Practice" many years ago – the identity of the "other" generalists (peds and IM) has certainly been threatened. Yes, yes … this isn't the message of Dr Centor's paper … he seems to be more concerned with pressure from the right — the specialists. But I would argue that there exists some pressure from the left (FP) as well.
It is not uncommon that I call an Internist friend to ask for advice in a situation that involves a very complex adult problem. Why? Because in some cases, the training of an Internist simply prepares them better for handling such situations. A good generalist knows the boundaries of his/her skill — and while most family physicians are capable of providing excellent care to children, adults, the elderly, and pregnant women — there are some situations in which we are better off having the help of someone who specializes. "You are worth it" I tell my hesitant patients. They sometimes seem to wish I could do everything for them. I can't. This is why we have specialists.
Yet with their identities as "general adult medicine" physicians — there is no good method for me to refer a patient to an Internist for consultation. Since they are primary care physicians – there is no "referring/consulting" physician relationship between Family Physicians and Internists (or Pediatricians) .. but I think that such an arrangement would be beneficial for all.
The "other" generalists may build a better understanding of what we do (many practicing internists and pediatricians didn't do a family medicine rotation in medical school) … and we may learn not to be so threatened by them.
Our Mantra seems to be "we provide the same care as they do." Which is accurate in many ways … and of course .. may be innacurate too .. since I would argue that a family physician may provide better care in many ways than an internist or pediatrician – especially for a family.
But the point is that if these physicians could re-frame their identities as specialists in complex adult medicine – no longer would they be positioned as competition for family physicians, but as an available, supportive adjunct to comprehensive, coordinated care.
Last week, a patient transferred out of my practice. She had complex problems that I frankly told her I didn't understand. She asked for the name of another physician who might be helpful, and I suggested an Internist colleague who works across town. Bottom line: our Internist pal figured it out. Something rare and complicated and I hadn't even thought about it. But she did … ordered the right tests, and I'm happy about that … but now the relationship with my patient is severed .. and .. yes .. my ego is bruised a bit.
Had I referred the patient to a rheumatologist or cardiologist etc etc … I wouldn't be severing the relationship with my patient — nor would my ego be bruised by such a situation. Indeed, assistance with the diagnosis and/or management of a complex problem is the purpose of such a referral.
Hmm … so, Dr. Bob (is that what DB stands for?) … how would this work? Referrals to the Internist … why not?