Tuesday, March 10, 2009

Do FPs do it better than internists?

A study in this month's issue of Health Affairs finds that Medicare spending by general internists and subspecialists is significantly higher than for family physicians.

The article's abstract says the following:

"Based on analyses of data from the 2001 - 2004 Medical Expenditure Panel Surveys, we found significant differences in annual spending, especially for adults. Use of and spending for subspecialists were similar to those for general internists, and both were significantly higher than those for family physicians. Variation in spending might be the result of training differences among primary care specialties." The article goes on to say that such "significant variation persisted after control variables and disease case-mix were adjusted for."

As a possible explanation for the variation, the authors cite another study, which concludes that "internal medicine resident training is not well suited for primary care populations." The article ends by saying, "Differences in the training of physicians who are serving as usual sources of care might account for different practice styles associated with greater and potentially avoidable spending, and thus it merits further investigation, particularly in light of current interest in the patient-centered medical home."

The study was conducted by the Graham Center, a research arm of the American Academy of Family Physicians.

I will leave it to others with more expertise than me to comment on the study's methodology and the suggestion that internal medicine training may not be well suited for primary care and the patient-centered medical home. I know that many internists will take issue with the study and the authors' discussion of the policy implications.

My concern is that at a time when family medicine, pediatrics and internal medicine are united on the need to institute policies to support primary care provided by all three disciplines, can there be anything more divisive than for each specialty to get into an argument over which one does the job better?

Vested interests who do not want to see primary care gain at their expense would love to see the primary care physician specialties get into a fight among themselves. Just like they would like to see primary care physicians and NPs battle over their respective roles.

This is not to say that we shouldn't do research to learn more about the impact of physician training on variations in effectiveness and cost of care. Such research should be subjected to critique and commentary, as I am sure the AAFP's Graham Center's study will be. But it will be regrettable if this article ends up creating a war of words on the value of family medicine versus internal medicine, when we should remain united on the essential contributions of both.

Today's question: What do you think of the Graham Center's finding that family physicians are less expensive than internists, and their suggestion that internal medicine training is not well-suited for primary care populations and the medical home?


encdinosaur said...

Would be nice to be able to read and evaluate the entire paper, but $135 per year for the privilege of reading Health Affairs is a bit steep for this primary care internist, who feels helpless to make much difference anyway!

It would be interesting to see the age distribution or year of completed training for the individual physicians involved.

If there was a not a significant age difference in year of finishing training, and these were relatively young physicians, there might be an answer.

My impression of "internists" finishing training now is that they are poorly suited for primary care, having trained in a hospital environment where frequent consultation and rapidly sequenced (or sometimes, needless and simultaneous) testing is carried out to empty a bed as soon as possible.

Primary care, on the other hand, recognizes that many symptoms or complaints are self-limited or will become self evident, as long as you have ruled out the ones with the earliest adverse outcomes with appropriate intervention. This takes some skill, a reorganization of thought processes for sequencing diagnoses, and a degree of trust on the part of the patient.

I would not doubt that younger FP's may be spend less than younger IM's under the circumstances.

Even thirty years ago, I had to "learn" to provide primary care, and continue to "learn" today.

Jay Larson MD said...

The study is based on self reported data such as "general physical and mental health". Heck, I have patients with diabetes, coronary arterial disease, reflux, renal insufficiency, hypertension, lipid disorder, and osteoporosis who consider themselves in good physical health. The main difference in spending between the FP and IM docs was that the IM docs prescribed more medications, had more office visits, and ordered more tests than FP docs. This may be a relection of more complicated patients. Comparing a patient with 1-2 chronic illness to a person with 6-10 chronic illnesses is virtually impossible. This study is hardly anything to support evidence that there is any difference in the care provided by an FP or an IM doc.

If you look at Medicare spending across the country, there is lower spending per Medicare receipient in western states compaired to the east coast. Should the same arguement be used that western state are better than east coast states...absolutely not.

What should be focused on is the end result..how healthy are people. The Robert Wood Johnson Foundation put out a report ranking the states from healthiest to least healthy. With the exception of Utah and Idaho, the top 10 states had 96-120 PCPs per 100,000 population. The bottom 10 states had 64-85 PCPs per 100,000.

In regards to the training of IM docs, outpatient care is much different than inpatient care and there should be more exposure to outpatient care.

Bohdan A. Oryshkevich, MD, MPH said...

If internists see more complicated patients they should not be calling themselves primary care physicians. That confusion is basic. Internists have to define the middle ground and that is never easy.

I have worked in both fields. I identify as an internist primarily and drove my FQHC employers crazy with my thoroughness. Yet, I discovered a lot of very serious medical problems in the FQHC where I worked. Neglected renal failure, pre-eclampsia coming in as sore throat, an ASD with pulmonary hypertension, CAD. Scores of hypertensives, diabetics, and other problems not adequately treated or addressed with totally inadequate or poor documentation.

As I was leaving I identified a syphilis patient that had not been inadequately treated. I had identified him ten years before but no one read my note on the front sheet, my notes or referred the patient back to me. He came back on a regular basis all for immediate problems.

A young doctor came in and started seeing 80 patients a day in an eight hour slot. He obviously missed problems but the inner city patients wanted their sore throats treated but their underlying problems overlooked.

I think that the FP can see the problem at hand. The internist will look more at the long term patient and see the need for treating the whole patient. The poor inner city patients did not understand and did not care about their health. They did not understand the difference of primary care and internal medicine.

I am not an American internist since I trained in Canada. I did physicals and not as many lab tests.

I think that the FP can work better in a high volume environment. But I do not think that he can manage patients or dig into cases thoroughly. We have a fundamental problem in confusing primary care, with a medical home, with clinical diagnosis in a quick and effective manner, and with internal medicine in this country. The ACP includes primary care doctors, internists, specialists and probably even overutilizing subspecialists. Then there is the SGIM.

I would put the internist as the physician as a sweeper as in soccer. He is the doctor standing behind the primary care doctors to deal with the more complicated problems, with the diagnostic dilemmas, the not self limited diseases, with the more difficult consultations with patients, and with keeping the technology and the subspecialists in check. I always feel proud when I send a patient to a neurologist or a hypertension specialist or a cardiologist, and my diagnosis to the patient is confirmed or the patient comes disappointed that the specialist was less thorough or conversant than I was.

I also think that the internist has to preserve and develop the language of medicine. The primary care physician is a screener. The specialist is filled with technical jargon and overly concerned with physiology and mechanisms. The internist should be controlling the language and culture of patient centered care. He should be integrating all the information of the screener, the subspecialists, the x-rays, the insurance companies and be the ultimate advocate of the patient. The primary care doctor wants to take care of the immediate problem. The radiologist or the pathologist is filled with descriptions of often abstract shadows.

The internist has to know a lot of stuff. Debt and proceduralism has eroded internal medicine. Performance based measures stress it.

The reality is that imaging and basic biomedical research has taught us much about human illness. One of the functions of the internist would be to collate the studies from imaging, lab tests and simplify them and make them patient centric and replace them with simple clinimetric measures.

For example, I am a board certified allergist and immunologist. Recent research into aerobiology and allergic rhinitis and asthma have turned atopy and allergy from a mysterious cottage industry (even to internists) to a relatively straightforward illness that can easily fall into the purview of the general internist.

The time has come for internists to stop being defensive and to integrate a variety of practices under their umbrella. That would be for the benefit of medicine.

Robert W Donnell said...

Where is it written that internists should not be different from family practitioners? General internal medicine is on life support and will soon cease to exist if the ACP doesn’t do a better job of promoting it as a unique specialty. I elaborate in a post of my own this afternoon.


Unknown said...

"I think that the FP can see the problem at hand. The internist will look more at the long term patient and see the need for treating the whole patient. The poor inner city patients did not understand and did not care about their health. They did not understand the difference of primary care and internal medicine."

Ummm... our specialty prides itself on treating the whole patient. This paragraph is pretty offensive.

To suggest that internists somehow care for more complicated patients than family docs is completely ridiculous. As you state, patients don't know the difference between IM and FM trained physicians, so why would a patient with more comorbidities end up with an internist versus a family physician?

As for inciting a "turf war," I don't think that's the intent. I think the intent is to underscore that IM training is more skewed toward inpatient medicine than towards outpatient medicine, when compared with FM, which may result in more health care expenditures. Maybe it just means that IM needs to focus more on outpatient practice.