The Healthcare Entrepreneur Blog

Is traditional internal medicine dead? – A guest post by Dr. Steven Knope

by Tannus Quatre PT, MBA | April 12th, 2010 | 5 responses

Introduction by Tannus Quatre PT, MBA

I am pleased to post the following commentary from Dr. Steven Knope, an internal medicine specialist and concierge physician located in Tucson, AZ.  I had the pleasure of befriending Dr. Knope a few years ago, and since that time have enjoyed thoroughly Dr. Knope’s perspective on medicine, and vision for the future of healthcare.  Dr. Knope’s book, Concierge Medicine: A New System To Get The Best Healthcare, is an excellent read and an important lens through which our country’s current struggles with delivering the best healthcare can (and should) be viewed.

A true healthcare entrepreneur, it’s my privilege to post the following commentary from Dr. Knope titled, “Is Traditional Internal Medicine Dead?”
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Is Traditional Internal Medicine Dead?
by Steven Knope, MD

For the last several years, writers in the New England Journal of Medicine and the Journal of the American Medical Association have authored doomsday editorials about the prognosis of primary care medicine. There has been much discussion about the fact that internists and family practitioners cannot keep pace with rising overheads and falling reimbursement under the traditional third-party payment system. Paraphrasing a recent story published in The New York Times, an internist in Massachusetts who practices under the new RomneyCare program said this: “Every time I see a Medicare patient, it is the equivalent of giving them a ten-dollar bill. I have a six month wait to see a new patient. I run from room-to-room. I can barely make my overhead. I’ve never felt so disrespected in my entire life.”

So is this all just whining and political hyperbole or is internal medicine really dying? The answer to this question was revealed to me by a colleague last weekend while I was at the hospital. I had been called to the ER for one of my patients who was hemorrhaging on the blood thinner, Coumadin. The ER doctor looked at me and said, “You are a dying breed.” I laughed and said, “Yes, I know…but why do you say this?” He responded, “See that list of 9 doctors’ names and phone numbers up there on the wall? You are one of the last of 9 doctors who still admits his own patients to this hospital when they get sick. All of the other internists and family practitioners have abandoned hospital medicine and limit their practice to the office.” I knew that this was a profound statement and it shocked me; but I did not fully digest its implications until I had stabilized my patient and started my drive home.

The hospital where I practice has over 700 doctors on staff. The fact that only 9 of us still take care of our own patients when they are hospitalized answered the question about internal medicine’s future. It is no longer an issue of whether traditional internal medicine can survive; the facts are – at least outside of the concierge model – internal medicine is already dead.

What are the consequences for patients? What happens to the average person in Tucson, Arizona when he or she gets chest pain, develops pneumonia or has a seizure? Can they reach their internist or family practitioner for a medical emergency? Most patients who call their primary care doctor for a medical emergency can’t even reach his staff during normal office hours. Instead, they will hear a recording on an answering machine, directing them to go to “call 911” for any medical emergency.

Once in the ER, the “doctorless” patient will be admitted to a hospital physician, who is unknown to them. This so-called “hospitalist”, who is a salaried shift-worker, will put in his 12 hours, and then go home. He is a doctor who knows nothing about the patient’s medical history. He has never met the patient. There will be no call from the hospital doctor to the primary care doctor in the office to get a thorough medical history. There will be no medical records transferred to the hospitalist. The hospitalist will attempt to get the best medical history he can from the patient, make some quick medical decisions, and then pass the patient off to one of his colleagues when his shift ends. And so it goes. No continuity of care, no understanding of the patient; the sick person now becomes a “case of pneumonia” or “the stroke in bed 3” to a group of unknown, rotating professionals.

As fewer and fewer young doctors go into internal medicine and family practice, and thousands of primary care doctors retire early due to financial pressures, the primary care shortage will only worsen. Not only will there be no primary internists to take care of their own patients in the hospital, there will be fewer internists available to see patients in the office setting. This inevitable vacuum of internists and family practitioners (traditional diagnosticians) will be filled by nurse practitioners and medical assistants; people with far less training and expertise than an M.D.. If you are fortunate enough to have a good nurse practitioner, you will eventually be referred to an appropriate specialist, who will treat one of your medical problems. If you are not so lucky, a nurse or medical assistant may miss an uncommon or rare diagnosis; he or she may misdiagnose the “headache” that is actually an aneurysm, the “flu symptoms” that turn out to be meningitis, or the “gallbladder problem” that turns out to be a heart attack. Bad things will inevitably happen when doctors are replaced by medical assistants. It is simply a matter of statistics. All doctors make mistakes, but those with less training make more.

As a concierge physician, people often ask me how this move toward a government-run healthcare system will affect me professionally. Speaking honestly, I tell them that it will help my practice, but I do not think this is good news for the country. As an independent concierge doctor, I am not subject to the rules or fees set by Medicare or Medicaid, nor do I deal with third-party insurance carriers or HMOs. I work for my patients, not a third-party with a conflicting financial agenda. As someone who practices full-service internal medicine, the demand for my services will continue to increase. However, this outlook about my own practice does not make me happy. I have small children. I am concerned about their future. I am concerned about what the changes in primary care will do the future of American medicine; what will happen if the art of internal medicine is completely lost. I am worried about what it will mean to the efficiency of medicine as a whole, to have no diagnosticians and clinicians to treat the majority of problems that do not need a specialist.

I have found a unique niche in medicine, which allows me to truly practice what I was trained to do. For most of my colleagues, however, this is no longer the case. They too were trained to care for patients from the office, to the hospital, to the ICU. Now, they no can longer afford to take care for their patients when they develop life-threatening illnesses. They are now “clinic doctors.” Their hospital skills have atrophied. They will never practice comprehensive medicine again. For them, the game is already over. For them, internal medicine is already dead. For their patients, and the society as a whole, this is a great loss.

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  • http://www.proaxistherapy.com burtonj

    What a great article…I appreciate the well thought out comments. There is major shifts to come in operating models all across health care.

    Your comments made me think of two things.
    1- Most aspects of healthcare will require a shift in their operating model to keep up with shrinking reimbursement.
    2- This type of change has been inevitable for more than 15 years. Healthcare has been inflating wildly for too long.
    3- There is a great opportunity to create better ways for patients to be treated with the existing resources within healthcare. If we don’t align these well now, we’re going to lose great physicians like yourself, and many more to come from future generations.

  • http://www.art-of-patient-care.com Greg Warth

    I too am very concerned about the future of primary care and health care in general in this country. I am hopeful that traditional primary care is not completely dead yet, but rather just waiting for a time when its value will again be recognized. Perhaps the concierge medicine movement that is occurring now will at least keep the meaning of patient-centered primary care alive while waiting for this to happen.

    While concierge medicine definitely fulfills a need that traditional care doesn’t always provide, there is still a great need for general primary care that concierge medicine economically and statistically can’t provide, since there will just not be enough concierge doctors to take care of the needs of nearly 300 million people – at least not in the foreseeable future. Recent health reform did very little to improve the plight of primary care. For traditional medicine to survive, Medicare, Medicaid and other insurers must provide the opportunity for primary care physicians to be paid what they are worth by eliminating the severe restrictions on their fees. Only then will students look at careers in traditional internal medicine and family practice as viable options.

    In the meantime, thank goodness we have concierge physicians to carry on the good traditions of patient care promoted by Sir William Osler. I’m glad to be one of them.

  • Jeff Ostrowski

    The April 13, 2010 Wall Street Journal had an article “Medical Schools Can’t Keep Up” which tells us experts predict a shortage of 150,000 primary care physicians in the next ten years to handle all the newly insured by health care reform.
    Arguably, this means longer waits and poorer outcomes on balance. That is unfortunate. However, there is one potential upside for our profession. It could open up an opportunity for PTs to serve in a primary care musculoskeletal role, thereby relieving volume pressure on primary care physicians.

  • http://hellohealth.com/physicians/ Shelley Myers

    I am fortunate to call several internists my friends and colleagues and, time and again, listen to their stories of day to day frustration about being on the ‘hamster wheel’ of medical practice. Some describe it as being on a treadmill that’s moving too fast…they are working as hard as they can but still they are flying backwards. They run and run, patient after patient, hours spent on non-reimbursed phone calls, emails, care coordination and can’t seem to move ahead. There is little job satisfaction and freedom to run their practice the way many small business owners or entrepreneurs do in a consumer-driven market where value is key. They are handcuffed by complex payer contracts which continually diminish the physician-patient relationship and dilute the physician’s time.
    Doctors, now more than ever, need to think outside the box, be creative, find ways to investigate and measure what their patients find valuable and what they will pay above their insurance co-pays such as virtual consults for follow-up visits or 24/7 access via phone or email. These are the doctors who will be our future PCPs and happy PCPs at that.
    There is good news when it comes to being a primary care doctor but some need to take a step back, step off the hamster-wheel for a bit to reflect on how they are running their practice, how they are marketing themselves, their services, the value they are providing or would like to provide. Are they connecting with patients through social media? Are they educating their market on what differentiates them from Dr. Smith down the street through blogging or publishing a monthly newsletter on their website? Very few are but need to consider adding these tools to their current marketing efforts. Patients and consumers are out there seeking out that special doctor who will give them the time, compassion, understand their lifestyle and behaviors, empower them to be a partner in their care. This is not for every physician, but for many there are other ways to practice medicine where they can be creative, entrepreneurial, and enjoy their profession. They just need the tools, the guidance, the support, the ideas, the motivation to get off the hamster wheel. Let’s keep primary care alive and well and our patients happy and healthy!

  • Used to be Worried.

    I have tried to practice traditional medicine with longer appointments and personalized service without charging the premium but I made the mistake of choosing an OVERSERVED market. Now that medicine is officially 99.9% business, the supply/demand curve sunk my practice so I must join the group that treats a doctor visit like a donut or a cd player. The guy who makes the cheapest one gets the customer. It is sad but I am convinced. People are starting to treat the doctor-patient relationship like the customer-clerk relationship. Not what I signed up for but what I must live with to make my dollars…