Hospitalists have no choice but to develop these skills. Working in the hospital, which is evolving to a new institution in real time, hospitalists must provide leadership and be part of a functioning team that can measure their work product and devise ways of making it better. This accountability to our patients and our community is essential and will happen with or without us.
But these same skills are needed for the majority of healthcare that occurs outside the walls of the hospital. The gift of today’s technology and treatments is the fact that people who previously would have died have been saved, and many who were treated as inpatients are now managed even better as outpatients. In many ways, my generation—the baby boomers—as consumers of healthcare expect to have our key physicians be not so much the magician who snatches us out of extremis at the height of acuity, but to have the knowledge and skills to see us in all of our aging and complexity and to partner with us to keep us well and functional for a very long time.
There is an opportunity to reposition internal medicine into a new status of power and influence based on a revised set of skills and performance. It is time to create the value proposition and then reset the reimbursement system and not the other way around. While the eventual “buyers” of this value will be the senior citizens, the first people we need to influence are medical students (i.e., potential future internists) and the purchasers of healthcare (i.e., business and government)
Here is the pitch to a world with an aging population that has an average of five diagnoses and six medications and a burgeoning array of diagnostic and treatment options—many of which are both expensive with an uneven proposition that they are cost effective: Internists will leave the routine primary care practice to others. Instead internal medicine will reinvent itself to be the doctors who want to see the highly complex patients and coordinate their care. We will have a broad knowledge so patients won’t need to necessarily be shunted to three or four specialists, but if a patient needs specialized care beyond our scope, we will know where to send them, and more importantly we will be prepared to take back the complex patient and manage them continuously over time.
We will be accountable. We will measure our performance, but more importantly we will take a leadership role in setting standards and implementing quality improvement. We understand we may be less than perfect initially, but we pledge to be better in three months—and three months after that. Because so much of healthcare requires multiple perspectives and support, we will be the leaders in developing teams of health professionals.
Internal medicine will once again be important and relevant—to medical students, to other health professionals, and to our patients. We will be central to the evolution of healthcare because the skills of measurement, information management, quality improvement, working in teams, and leadership are what everyone wants, and no one specialty has been seized as their own. This is tough stuff and it is under-rewarded by our current system of payment.
If we have learned anything it is that the work is the reward and leads to career satisfaction, and that there is little correlation between compensation and happiness for physicians.
I fear if internal medicine is not reinvented immediately, it will cease to exist. And that will be very bad for our patients and not particularly a good thing for those who should have been internists and end up being dermatologists. TH