Generating More Generalists: An Agenda of Renewal for Internal Medicine

Medical School

The reasons for the waning interest of medical students in internal medicine extend beyond the reach of undergraduate medical education. They include the attraction of new technology, high expectations regarding income, and the appealing lifestyle associated with more specialized fields. Experiences during medical school, coupled with the personality types of students selected, affect specialty choice. A department of medicine is the centerpiece for clinical teaching: If staff are committed to train more generalists and to redirect their energies to that end, they should be able to attract students to careers in general internal medicine.

If this is to occur, departments of medicine must place a higher value on the unique role played by generalist faculty members. Staff must take explicit steps to recognize the value of generalism by promoting professionalism and collegiality among generalists and subspecialists, by identifying and eliminating institutional bias that encourages subspecialization over generalism, and by ensuring that students have educational opportunities with practicing internists in the community.

Action: Serve as a catalyst for change: Place a high priority on educating generalist physicians. To meet this goal, medical schools and their departments of medicine must take the following actions:

1. Admissions

- Support no increase in medical school class size. Further increase in physician supply is not a cost-effective solution to the country's access problems, which are related to the maldistribution of physicians by specialty and location.

- Ensure that an appropriate number of generalists serve on the Medical School Admissions Committee.

- Develop admissions criteria that promote the selection of students with an interest in generalism.

- Reduce indebtedness for students selecting generalist careers.

2. Administration

- Invest departmental resources in faculty development programs designed for generalist faculty.

- Establish mentoring programs for students, residents, and fellows interested in general internal medicine.

- Create a division of general internal medicine within the department of medicine if one does not already exist.

- Provide academic recognition of generalist faculty for excellence in clinical teaching as well as in research.

- Motivate faculty, students, and residents to pursue research in general internal medicine.

3. Curriculum

- Alert students to the serious shortage of primary care physicians and the increasing career opportunities for general internists.

- Involve general internists early in the curriculum.

- Emphasize development of the special knowledge and skills essential for successful generalist careers.

- Expand the opportunities for teaching medical students in ambulatory care settings.

- Increase the number of practicing general internists in the community who are actively involved in teaching medical students.

- Collaborate with other specialty departments (for example, pediatrics, family medicine, obstetrics-gynecology) in sponsoring integrated primary care experiences for medical students and residents.

- Develop a transition program to bridge the fourth year of medical school and internship that would 1) identify early those students interested in general internal medicine and 2) empower the clerk ship directors to enrich the fourth year of the medical school curriculum by including a coordinated undergraduate-postgraduate curriculum of experiences relevant to the education of general internists.

Residency Programs

Entry into internal medicine residency training is affected by experiences in medical school and residency, both of which currently reflect the substantial influence of the nongeneralist specialties and the declining interest in primary care. Although little is known about the factors that might directly enhance generalist career selection, programs that produce a high proportion of generalists should be studied and emulated. Likewise, programs training large numbers of resi dents who subsequently pursue subspecialty training should be encouraged to shift the balance toward generalism.

The current structure of funding for graduate medical education limits the opportunity to create special incentives for residents in the generalist specialties. It also affects the ability of program directors to fund initiatives designed to increase the number of generalists and decrease the number of subspecialists.

Most internal medicine residents are trained in urban medical center hospitals, many of which have large service commitments and limited access to the broad spectrum of patients and diseases characteristic of general internal medicine. Although exposure to highly specialized care and the severely ill patients often seen in these medical centers is important to the education of the general internist, these experiences are not in themselves sufficient and service demands often dominate.

Action: Redirect graduate medical education toward the production of more general internists by requiring the following changes.

1. Ambulatory Care Experience

- Extend ambulatory training for internal medicine residents to increase continuity care of patients as well as experiences with medical problems often encountered in the practice of general internal medicine, which are often seen in dermatology, gynecology, and otorhinolaryngology clinics.

- Incorporate experiences in managed-care systems.

2. Inpatient Environment

- Schedule most inpatient rotations on general internal medicine services.

- Assign more general internists as attending physicians.

- Emphasize continuity of care as part of the continuum of patient care and patient-centered education.

3. Curriculum

- Develop and sustain residency curricula that focus on preparing residents for practice as generalists (for example, multidisciplinary ambulatory experiences, training in psychosocial and interviewing skills, and practice management).

- Re-evaluate the obligation for teaching internal medicine to residents training in other specialties.

- Identify a portion of funding for graduate medical education that will be available to support innovative curricula in internal medicine and the development of training sites and faculty in nonhospital settings.

- Base the number of residency positions offered in internal medicine and all other specialties on national or regional physician workforce needs and not on hospital service requirements.

4. Financing for Graduate Medical Education

- Work with others to develop an all-payer national financing system for graduate medical education.

- Reimburse community-based clinicians for their participation in resident education through direct stipends administered by residency programs or through payment supplements by third-party carriers for patient services.

- Increase grant support for innovative residency and fellowship programs that foster educational reform and serve as educational laboratories to facilitate curricular initiatives and faculty recruitment and retention.

- Encourage revision of Medicare payments for direct graduate medical education to emphasize primary care training, with provision for a greater portion to be used to provide increased stipends for primary care physicians.

- Advocate other measures, such as low interest loans, loan forgiveness programs, and reinstatement of the Berry plan [3], to provide direct financial incentives for physicians who choose careers in general internal medicine and other primary care specialties.

5. Faculty Development

- Invest departmental resources in faculty programs to develop generalism that are designed for both generalist and subspecialty faculty.

6. Advanced Training

- Offer education in general internal medicine beyond the minimum 3-year requirement to acquire advanced clinical and research skills.

Subspecialty Fellowships

The internal medicine community must take action to reduce the number of medical students who choose to specialize but must not decrease the overall number of medical students who enter 3-year internal medicine residencies. Decreasing the number of subspecialty fellowship positions can be accomplished in several ways. Internal medicine must join with all other specialties in a coordinated effort to reduce the excess number of highly specialized trainees [4]. The interest of medical school graduates in generalist specialties, as shown by the choice of residency training, has dropped in comparison with interest in other specialties such as anesthesiology, dermatology, radiology, and the surgical subspecialties, including ophthalmology. Therefore, unilateral reduction of medical subspecialty training opportunities could adversely affect the quality of medical students who enter 3-year internal medicine residencies if those students currently seeking medical subspecialty training are channeled into other disciplines.

The question remains, Which subspecialties of internal medicine should be reduced and by how much? Cardiology and gastroenterology are most frequently identified as needing to reduce their numbers. The training and career pipelines are long. At least half of the cardiologists now in practice completed training since 1980, and, unless their ability to practice cardiology is compromised in some way, most of them will continue to be in active practice until the year 2025. Therefore, policymakers and planners must consider both the short- and long-term options available.

Action: Use the following mechanisms to reduce the number of subspecialists being trained.

1. Training Positions

- Support a comprehensive approach to physician workforce management: Advocate formation of a commission that would set numbers of training positions for all medical specialties, as recommended by the reports of the Council on Graduate Medical Education, the Physician Payment Review Commission, and the Macy Foundation Conference on Graduate Medical Education [5-7].

- Maintain subspecialty fellowship programs that have proved successful in training physician scientists and academicians.

- Reduce the number of subspecialty training positions by eliminating programs of marginal quality.

- Reduce the number of subspecialty fellowships in other programs while taking into account 1) the need for house physicians or other health professionals to provide patient care in teaching hospitals that traditionally has been provided by subspecialty trainees; 2) the need for additional faculty to replace subspecialty trainees, who now teach housestaff and students and are providers of patient care; and 3) the diminished attractiveness of careers in internal medicine because of reduced opportunities for subspecialization.

2. Financial Support for Training

- Ensure that the National Institutes of Health and the Veterans Affairs funding for research training is not used to increase the supply of clinical subspecialists.

- Support training for physician scientists in the subspecialties, provided trainees can guarantee commitment to research careers. (During the past 15 years, the number of physician scientists in academia, government, and industry has not increased.)

3. Length of Training

- Lengthen subspecialty training to ensure that trainees acquire the requisite competence and experience, given ever-expanding medical knowledge and technology.

- Increase the number of years of training required to become eligible for subspecialty certification by the American Board of Internal Medicine without increasing the total number of subspecialists in training.

- Establish more opportunities for general internists to provide more varied and complex patient care.

Practice Environment

Specific, comprehensive measures are needed to improve the environment for practicing internists and other primary care physicians to encourage physicians, both in training and in active practice, to remain in internal medicine. Legislative action must be taken to improve and reform current payment policies. In recent years, financial inequities and administrative burdens have produced major disincentives for physicians entering or remaining in primary care, whereas economic incentives for the subspecialties have increased dramatically. Only by enacting legislation that supports economic incentives and regulatory reform for generalist physicians will the public be assured of access to primary care services in the future.

Action: Encourage the Federal Government to take the following immediate actions relevant to the practice environment of general internists.

- Decrease regulatory and administrative burdens, which will improve both physician and patient satisfaction.

- Provide equitable payment for services to motivate physicians to choose careers in internal medicine and other primary care specialties. Specific steps include 1) acquiring data for practice expense using resource-based methods; 2) modifying any method of volumes performance standards on budgets to protect primary care or generalist services; 3) assessing the effects on primary care practices of proposed regulations and other administrative requirements before implementation; and 4) examining the effects on primary care physicians of the current methods of conducting Medicare utilization review and proposing changes to reduce intrusiveness, red tape, and costs of compliance.

- Improve the career satisfaction of the general internist through changes in long-term government and private sector policies. Specific steps include 1) providing incentives to maintain appropriate rewards for generalists and 2) encouraging the development of administrative management and clinical support systems for general internists within the practice environment.

Reorganization of Health Services

Health care reform will force changes in the way physicians, other health care providers, and administrators work together to form organized delivery systems. These systems require collaboration among disciplines, joint governance, and integration of inpatient, office practice, and other settings. Their implementation may result in an improved practice environment, decreased practice costs, and better patient care. In reorganizing health services, physician assistants and nurse practitioners can serve to further extend the patient care provided by physicians.

Action: Maximize the contribution of physician extenders by defining precisely how they will function in concert with generalists to assure patients access to primary care.

- Define how physician assistants, nurse practitioners, and other health professionals can be used to both reduce the service workload of general internists and enhance patient care.

- Consider the ramifications of training more physician extenders concurrently with more generalist physicians. For example, will increasing the number of generalists lessen the need for extender services in the future?

- Acquire information on the cost effectiveness and utility of physician extenders in practice settings.

- Clarify the extent to which internists' efficiency in patient care can be increased by improved administration and information management in the practice setting.

Continuing Medical Education

Any plan to increase the nation's capacity to provide for the health care of adults must take into account the many internists who currently practice subspecialty medicine. Many already provide general medical care to their patients with subspecialty problems, and some also care for patients without medical problems in their subspecialty. Although trained as generalists during residency, some subspecialists may be unprepared for the current practice of general internal medicine and require additional educational experiences outside their subspecialty.

Action: Promote life-long learning and continuing medical education by encouraging the following:

- Support self-assessment and recertification of internists based on comprehensive examinations relevant to clinical practice.

- Provide continuing medical education courses that include balanced exposure to new knowledge in the subspecialties and instruction in general internal medicine, incorporating such topics as prevention, behavior modification, information management, medical decision making, technology assessment, clinical epidemiology, and clinical ethics.

- Establish courses to help subspecialty internists retrain as generalist physicians.

- Reduce dependency on commercial support of continuing medical education and work toward securing stable, adequate funding from nonprofit organizations and other sources.

Conclusions

To meet the challenge and to achieve the goal of generating more generalists, FCIM is dedicated to working collectively and collegially to implement an agenda of renewal for internal medicine, one designed to achieve the following:

- Enhance the medical school curriculum for generalism.

- Redesign residency training to promote generalism.

- Limit the number of subspecialists and the growth of subspecialties.

- Improve the practice environment for the generalist by providing adequate reimbursement and by eliminating hassle factors.

- Explore the use of physician extenders as a way to foster more efficient delivery of patient care by general internists.

- Provide new training opportunities and incentives for certain subspecialists to become up-to-date generalists.

The FCIM member organizations agree that they must continue to find effective ways of working together (in order to) speak with a unified voice, identify areas in which they can have a real impact, and promote realistic solutions [8]. This agreement has resulted in a renewed commitment by the internal medicine community to find solutions to the dilemma now facing the specialty of internal medicine and its ability to meet the health care needs of the nation.

This paper was presented in part at the American Board of Internal Medicine Summer Conference on 10 August 1993 in Sun Valley, Idaho.