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Departments of internal medicine: Upright or supine?
PRESIDENTIAL ADDRESS Departments of internal medicine: Upright or supine? KARL T. WEBER COLUMBIA, MISSOURI
ur coming together on the occasion of this plenary session offers us a unique opportunity to address issues of major concern to departments of internal medicine. Challenging issues that have arisen as a result of health care reform that is sweeping this nation. And what began as reform, directed at controlling health care financing, has culminated in a revolution that has affected health care delivery, medical student and resident education, and research. A revolution that has mandated revisions in department structure and operation. My purpose will be to focus on department restructuring. I would hasten to add that although necessary, restructuring must not occur at the expense of major missions in patient care, education, and research. Indeed, in today's climate ot reform, where the potential for innovation abounds, departments have the opportunity to enhance on these missions. I will address the topic of department restructuring mindful of the Council on Graduate Medical Education's fourth report to Congress and the Department of Health and Human Services.t In this report the Council on Graduate Medical Education indicated a stated goal to be the following: "All primary care shortage areas should be eliminated and disparities between metropolitan and non-metropolitan distribution of physicians should be reduced." It is my firm belief that planning and implementation of department restructuring must simultaneously take into account the needs of our
O
From the Department of Internal Medicine,Universityof Missouri Health SciencesCenter. Submittedfor publicationOct. 21, 1996; revisionsubmittedOct. 21, 1996; accepted Oct. 21, 1996. Reprint requests: Karl T. Weber, Universityof MissouriHealth SciencesCenter,Departmentof InternalMedicine,IVlA432Medical SciencesBldg., Columbia,MO 65212. J Lab Clin Med 1997;129:273-80. Copyright© 1997by Mosby-YearBook,Inc. 0022-2143/97 $5.00 + 0 5/1/78951
society--most important, the provision of high-quality care to the medically underserved populations of this country. This may seem far-fetched to academic health centers consumed by a doomsday attitude, where maintaining "vital signs" is the overriding priority and self-preservation transcends innovation and altruism. Shedding this perspective for a vision that extends beyond expressways to roads less well traveled may address both survival and success. THE CHALLENGE: HEALTH CARE REFORM
For the past decade departments of internal medicine throughout this land have heard the shrill warning call of our federal government's klaxon-prepare for health care reform! From the American Board of Internal Medicine, Association of American Medical Colleges, and American College of Physicians clarions were sounded summoning departments-react to these changing times, where managed care and capitation are rapidly replacing indemnity plans and fee-for-service medicine! The collective cacophony heralds a need to reorganize department structure. Does this mean departments should operate in a vertical or horizontal mode? Are we upright or supine? Given these uncertain times, a concern for department viability has arisen in some quarters. Senior statesmen festooned crepe at department doorways with inflammatory rhetoric to gain attention. "Internal medicine may be in its twilight because it has failed to address the shortage of primary care physicians by training more general internists. ''2 "We cannot continue to train the old-fashioned internist... We're dying. What the nation wants is primary care physicians, and that is what training programs must produce. ''3 " . . . we seem to be losing the battle in internal medicine in the medical school itself.''4 Perhaps our interest in programmed cell death, or apoptosis, has brought to the fore concepts of a "death wish" with death promoter effector pathways. Are departments of internal medicine about to disappear? Are we upright or supine? 273
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DEPARTMENTS OF INTERNAL MEDICINE Clinical Services
Vertical Integration: Interdepartment Service Lines
1
2
3
Fig. 1. Example of vertical integration between three departments.
PATIENT CARE: UPRIGHTOR SUPINE? In providing patient care in an ever-expanding managed care/capitated environment, departments must reorganize. The traditional independent mode of operation must be broadened to include coordinated, interdepartmental service lines--vertical integration within an academic health center (Fig. 1), and integrated intradepartmental services between divisions that eliminates redundancies and fragmentation-horizontal integration that blurs divisional boundaries (Fig. 2). Each department must find its own formula for success based on its strengths, the patient population it serves, and its geographic location. Nonetheless operating in both a vertical and horizontal mode, upright and supine, seems sensible. Success in a managed care/capitated environment depends on several well-known factors, which need reemphasis. First, an ability to win contracts and attract, then retain, patients. Second, an ability to manage care and optimize expenditures within a capitated payment schedule, where each component of health care delivery has become a cost center. These factors mandate the need for a coordinated, large medical group--an alliance of hospitals and physicians--that can joint venture and negotiate, have the ability to continually innovate, coordinate the continuum of care, monitor quality of care, and enact agreements in an effective and efficient manner.
A network of primary care providers is the foundation on which to build and achieve these objectives. This network includes general practitioners, family practitioners, general internists, and pediatricians, each of whom reside within an academic health center and its neighboring communities. It is this network that will manage the full continuum of patient care. It is mandatory that there be a culture of cooperation and common purpose--a single-minded attitude toward patient care in keeping with a collaborative, multidisciplinary group practice. This attitude must be operative within the academic health center and its partners in the community. Department chairs must foster this attitude and promote unified ownership in patient care, effective integration at all levels, and productive use of specialists. An attitude of entitlement, or sitting at home awaiting the referral, will lead to the refrain: "splish, splash, I'm taking a bath." In a culture of mutual education specialists must optimize the practice and education of primary care providers. To optimize patient care specialists must share certain technologies with these partners. There must exist the potential for cross-fertilization between specialists and generalists in an innovative system of care. 5 Departments of internal medicine must serve as guardians to their specialists: promoting their integration and effective use as a network of service lines within the academic health center,
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DEPARTMENTS OF INTERNAL MEDICINE Clinical Services Horizontal Integration: Intradepartmental Services
Fig. 2. Example of horizontal integration between division within department.
establishing practice guidelines for specialists in the form of critical pathways, short stay, observation units, and guarding against antispecialist sentiment that would suggest these highly trained physicians are simply technology-driven and short on cognitive skills. Can all this be accomplished while meeting society's need to reduce health care shortage areas? What is the magnitude of the underserved population? Every state in the United States has health care shortage areas--both urban and rural. According to 1995 data of the Shortage Designation Branch of the Bureau of Primary Health Care, 6 there are a total of 2795 primary care shortage areas in the United States, and of these more than two thirds (1845) are nonmetropolitan. According to the Office of Rural Health Policy more than 50 million Americans live in rural areas, of whom nearly one hall 22.5 million, are medically underserved. 6 Only 9% of our nation's physicians practice in rural communities. The Federal Register identifies both underserved and served rural and urban counties within each state. From data found in the 1995 Federal Register7 the density of rural to urban shortage counties was determined by taking the ratio of rural underserved to urban underserved counties in each state. Densities were then subdivided into relative densities termed: none to low (ratio 0 to 1.0), found in 10 states; mild (ratio 1.1 to 1.99), present in 9 states; moderate (2.0 to
6.0), in 21 states; and severe (>6.0), found in 8 states. Rural underserved counties, represented by a ratio >1.1, predominate in 38 of the continental states. The same is true for Alaska and Hawaii. The density of rural underserved counties, again defined as the ratio of rural to urban underserved counties of >1.1, predominates in states located in the central, southeastern, and western regions of the United States. In the northeastern region urban underserved counties predominate. Fifteen states have been assumed to comprise the Central Region of the United States. Four of these states have a severe (>6.0) rural shortage problem; seven states a moderate (2.0 to 6.0) rural shortage problem, and three states a mild (1.1 to 2.0) rural shortage problem. Among central states Missouri has a ratio of rural to urban underserved counties of 5.4, representing a moderate density. It therefore could be considered representative of the rural shortage problem in the central region. There are 115 counties in Missouri; 64 are underserved, and of these 84% are rural counties. Missouri has 10,633 licensed physicians, with 9100 (86%) practicing in urban counties; only 1533 (14%) practice in nonmetropolitan areas, s The University of Missouri Health Sciences Center is located in the city of Columbia situated more or less in the center of the state. We have used a "hub and spoke model" to develop an integrated health care network that addresses both our patient care mission and our
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state's underserved rural counties. The model spans a 100-mile radius of Columbia and represents an academic health center without "walls." Each "hub" site has a hospital and is not designated an underserved county. We have already or are developing affiliations with these hospitals. At these hubs we provide outreach services for neighboring underserved counties that represent "spokes" served by each hub. Most spoke sites are within 30 miles of a hub hospital. The department of internal medicine initiated an outreach program in 1991. It drew on entrepreneurs at all levels, each of whom were willing to share risk in implementing this program, not the least of which included driving to these sites on a weekly basis. We began with one site. Over ensuing years our program has grown to include 10 hubs, where our specialties provide sought-after services. A specialist physician and nurse visit each hub on a regular basis, where they render scheduled, consultative services and interact with referring primary care providers. Our medical center's practice plan has developed affiliations with primary care providers within the hub and spoke model. In some cases the practices of primary care providers have been purchased, and these physicians formally integrated into our practice plan and faculty in internal medicine. The department has already placed and will continue to strategically place graduating residents at these sites, where they serve as general internists. These graduates are members of our faculty, our medical center's practice plan, and our affiliated network of physicians. Our medical school's federally and privately funded telemedicine program links our academic health center to these hubs in an efficient and economic manner. It provides primary care physicians with consultative, radiologic, educational, and research services. It provides health access to rural areas in a culture of cooperation, common purpose, and mutual education. In addition to providing health care to rural underserved counties, it is our hope that these collective strategies meet several additional objectives: reduce the sense of isolation that primary care providers at underserved rural shortage areas may experience and foster recruitment and retention of primary care providers at these sites. 6'9 The Bureau of Health Professions estimates that 2183 physicians are needed to remove all designated nonmetropolitan shortage areas. 6 However, if our target is 1 primary care physician for every 2000 people, then a total of 5257 such physicians are needed, suggesting that we will not have a surplus of primary care providers for some time to come.
What about specialists in Missouri? Is there a surplus or rather a maldistribution? Our 10 hub and spokes vary in size based on population served: four are large, serving a population of 90 to 120,000, three are medium, with a population of 50 to 60,000, and three are small, serving a population of 30 to 40,000. The total population served is approximately 700,000. Based on health maintenance organization staffing patterns, physician workforce requirements were estimated by Weiner. 1° This included the number of medical specialists needed to serve each population of 100,000. Based on these projections more than 100 medical specialists are needed in the underserved segment of mid-Missouri represented by our hub-spoke model. Some are already in place. 11 Others, practicing elsewhere, need to be recruited. Will they relocate? Will relocation only occur if their current metropolitan-based practice fails? 12 We plan to strategically place specialists at appropriate underserved sites, where they can either function as team leaders for patients with complex illnesses and specialized needs, or practice costeffective medicine when primary care providers are not in place. At some sites outreach specialty services alone will address community needs. EDUCATION: UPRIGHT OR SUPINE?
I now would like to focus on our second mission --education. The Central Society for Clinical Research includes 40 departments of internal medicine. The Society has much reason to be proud, not the least of which are its member medical schools recognized for their commitment to primary care. According to the most recent U.S. News & World Report survey (March 18, 1996:96-97), 8 of this country's top 15 primary care medical schools are members of the Central Society (Fig. 3). This notwithstanding, there is much to be done with the restructuring of medical education. Reform that addresses the broader mission of an academic health center to include societal needs. Should we be upright or supine? Targeted curricular reform has many components, not the least of which should address specific needs: residents, who will practice in underserved shortage areas as general internists, generalists, who serve as mentors at underserved sites, specialists, who represent tomorrow's scientists, consultants, and mentors at academic health centers. Curriculum reform must be accomplished in a cost-effective manner given likely reductions in funding available for graduate medical education. Advantages are offered by interdepartmental or vertical integration--a culture of mutual education--
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PRIMARY-CARE SCHOOLS 1. University of Washington 2. University of Massachusetts at Worcester 3. Oregon Health Sciences University 3. University of New Mexico 5. University of California at San Francisco 6. University of Missouri at Columbia 7. Southern Illinois University at Springfield 8. University of Iowa 9. Michigan State University 10. University of Kentucky 1 1. University of Minnesota at Duluth 12. Medical College of Wisconsin 13. Univ. of Colorado Health Sciences Center 14. East Carolina University 15. University of Kansas Medical Center US News & World Report, March 18, 1996 Fig. 3. Ranking of primary care medical schools by U. S. News & World Report (March 18, 1996:96-97). Schools representing membership in Central Society for Clinical Research are highlighted (Copyright 1996, U. S. News & World Report. By permission).
wherein a sharing of core topics independent of clinical training is promoted. Epidemiology, biostatistics, ethics, and principles of molecular biology are examples of such economy of scale. Since 1991 our department of internal medicine has operated with a matrix model. Managers in this model include program directors, or associate chairs for clinical affairs, education, and research, that interact with each division, and functional directors, more traditional division directors. Our associate chair of education, for example, is able to coordinate and implement curriculum reform across divisions, an example of intradepartmental or horizontal integration. A matrix structure is a hybrid form of organization in which functional and program forms overlap. 13 It allows for coordination across functions in business units when the environment is complex and challenging. It balances power and emphasis between program and function. It allows for consolidation of costs and a rapid response to marketplace demands. Managers must collaborate with one another while they manage. Faculty must accommodate to each set of managers. Chairs must delegate authority and responsibility to both program and functional directors. Matrix is a process--a method of operation--it represents a department's anatomy. Its physiology allows information to flow throughout the organization; its psychology determines the at-
titudes of faculty and how they modify their behavior and priorities in responding to reform. Success in a matrix model is largely based on how faculty embrace such an operational structure and the effectiveness of its managers. Department chairs and medical schools may need to modify their behavior including criteria for promotion or tenure if they placed undue emphasis on independence, an attitude that isolates faculty and emphasizes egocentricity at the expense of the enterprise. An attitude that may explain why faculty viewed patient care as an intrusion and education as an imposition. Some, short on clinical skills, would hide behind a mantle of arrogance to overcome their insecurity. A sparsity of role models is not a surprising outcome in such an environment. 14 Others would now suggest academicians "are not necessarily team players. ''15 Patient care and education are not interruptions of our work; they are our work, and so is the health of the enterprise. Training residents for careers as primary care internists should be commensurate with the current practice environment and their eventual practice setting. Programs must have the flexibility to individualize resident training based on the where and what of their future practice. 16 The where addresses whether generalists will practice in urban or rural locations and whether either site is served or under-
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served. Ambulatory care and in-hospital training at such sites must be provided. Training in the principles of managed care and capitated services--that is, cost-effective delivery of high-quality care--is a requisite in either case. Graduating residents must be competent, confident, and compassionate physicians wherever they practice medicine. The what of a general internist's training at underserved sites may need to consider basic elements of gynecology, ophthalmology, otorhinolaryngology, orthopedics, pediatrics, physical medicine and rehabilitation, psychiatry, and family medicine. Yes, there is much to be learned from our colleagues in family practice. Toward these ends the hub and spoke model serves as an educational network. Such vertical integration with community with on-site primary care providers as educators can be incorporated into new curricula. Communities may wish to share in the costs of resident training. Such partnering enables a training program to draw up an individualized curriculum for its residents and to provide generalists to sponsoring underserved communities in accordance with need. Horizontal or intradivisional integration is needed for overlapping segments of specialist training such as future academicians dedicated to the basic sciences and clinical investigation. 17 Even more broadly speaking, horizontal integration should include a tearing down of barriers between specialties seeking common pathophysiologic expressions and mechanisms of disease. 18 For example, polycystic kidney disease is often associated with intestinal diverticuli, myxomatous degeneration of heart valve leaflets, and vascular aneurysms. It likely reflects a single gene defect and common disease process of unbridled proteolytic digestion of structural proteins by matrix metalloproteinases. 19 Tissue repair gone awry, expressed as a progressive interstitial fibrosis, is another. It can explain kidney, lung, heart, and liver failure in diverse settings, where collagen turnover by phenotypically transformed fibroblast-like cells (myofibroblasts) is abnormal and governed by locally generated peptides and polypeptides. 2° Faculty committed to the enterprise represent a creative wellspring that can be tapped in revamping and revitalizing educational programs for residents and students. A problem-based learning curriculum was recently implemented at our institution and has done much to encourage and accelerate student use of deductive reasoning; its principles can be used effectively in house staff training. A successful tool at our medical center is case-based medical myster-
ies with the detective, an internist, serving as integrator of diverse clues. 21 Educational reform must include Morning Report 22 and Professors Rounds, stalwart sessions of training programs. Irrespective of whether they take place in a hospital or ambulatory care setting, these sessions provide an opportunity to enhance resident and student understanding of pathophysiology and to develop reasoned mature judgement while mindful of health care costs. In this connection the importance of a skillfully obtained history and physical examination cannot be overstated. These principles, although self-evident, require that chairs and mentors spend less time "in the air," lest he or she leave the impression "if he doesn't care, why should I?" It's far more important in these times of reform to be locally available, prepared, and appreciated than to fulfill egocentric needs of national and international recognition. RESEARCH: UPRIGHT OR SUPINE?
Should a department's revamped research mission operate upright or supine? Through effective interdepartmental and intradepartmental collaboration and vertical and horizontal integration, new knowledge will emerge. Who better than departments of internal medicine to lead the way in bridging advances in molecular biology and genetics with the practice of medicine? We must fulfill this expectation of scholarly leadership. It is an expectation we cannot shy away from. It is essential to our viability. In my judgment the time is propitious for academic health centers to broaden their research mission and reach out. Self-contained and self-served no longer apply. Reform must include public service within their state and our nation. Centers need to assume a more active role in addressing societal needs and seeking innovative solutions to critical social issues. The medically underserved populations of our country, both rural and urban, represent such a problem. We must further recognize that research and innovation can be a friend o f cost containment.
Research topics a r e m a n y . 12'23'24 They should be population-based and patient-centered in nature with the integrated health care network to develop community-based services for disease prevention, effective delivery of health care for chronic illness, outcomes research to improve the scientific basis of everyday practice of medicine and to better organize care to produce improved outcomes at lower cost, practice guidelines for the use of new or established treatments, relative cost/benefit ratios of alternative technologies compared with health needs of the population served and the ability of the system to
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use new technology, work force needs in caring for populations served within the region, and education of involved populations regarding health and wellbeing. No matter what the scope of such a program is, the actual needs of the community must be determined with active involvement of community health care professionals and public leaders. Involvement that promotes self-help and empowerment rather than promoting dependency for their patient or their community. SUMMARY
In closing, I would reiterate that with the inevitable restructuring of departments of internal medicine, now is the time to develop innovative, interdisciplinary strategies to manage across boundaries. Strategies of vertical and horizontal integration within an academic health center and its alliance with the communities it serves. Strategies that will enhance our missions in patient care, education, and research. Recreate the environment that will once again allow nature to flourish. During this time of reform we are not strapped with sustaining the status quo. Opportunities for innovation abound. Innovation demands an ability to reallocate and adapt. Abandon old paradigms. Seize the occasion to reformulate, restructure, revitalize, and revamp--to write a new chapter. We are limited only by our creative potential and entrepreneurial spirit, or willingness to take risk. I ask you, who better than academic health (:enters to succeed in managed care? Corporate relationships between medical school and hospital already exist, and with innovative restructuring seamless delivery of high-quality care is a reasonable expectation. Seize the opportunity. I ask you, who better than departments of internal medicine to provide innovative answers to seamless delivery of primary and specialty care? But vision begets responsibilities. In formulating plans of reform we must rise to the challenge of solving critical societal needs. Medically underserved populations should be targeted for high-quality health care. Community-based patient-centered programs of education, research, and preventive medicine must be provided. Research can be the friend of cost containment. In placing a premium on synergies that will increase our potential, our productivity, and effectiveness in a culture of cooperation, common parpose, and mutual education, new knowledge for the twenty-first century will emerge and of which we can be justifiably proud. It will guarantee our viability. It will be our legacy.
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REFERENCES
1. Council on Graduate Medical Education. Fourth Report to Congress and the Department of Health & Human Services Secretary: Recommendations to Improve Access to Health Care Through Physician Workforce Reform. Washington, DC: US Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, 1994. 2. Petersdorf RG, Goitein L. The future of internal medicine. Ann Intern Med 1993;119:1130-7. 3. Gordon A, American Board of Internal Medicine. Report of the 1993 ABIM Summer Conference. The General Internist: Who, What, Where, When, How--And Why! Philadelphia: American Board of Internal Medicine, 1993:71. 4. Leavey G, American Board of Internal Medicine. Report of the 1993 ABIM Summer Conference. The General Internist: Who, What, where, When, How--And Why! Philadelphia: American Board of Internal Medicine, 1993:72. 5. Saultz JW. Reflections on internal medicine and family medicine. Ann Intern Med 1996;124:600-3. 6. Konrad TR. The problem of shortages of physicians and other health professionals in rural areas: empirical evidence and policy recommendations. In: American Council on Graduate Education, editor. Geographic distribution of physicians in rural and urban uderserved areas. Washington, DC: US Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, 1997 (in press). 7. Department of Health and Human Services HR and SA. Lists of designated primary medical care, mental health, and dental health professional shortage areas. Federal Register 1995;190:51518-655. 8. Rural Health Initiatives Committee. Rural Health Primer. Columbia, MO: University of Missouri, 1994. 9. Anonymous. Rural primary care. American College of Physicians. Ann Intern Med 1995;122:380-90. 10. Weiner JP. Forecasting the effects of health reform on US physician workforce requirement. Evidence from HMO staffing patterns. JAMA 1994;272:222-30. 11. Weiner JP. Internal medicine at the crossroads: training subspecialists for the next century. Ann Intern Med 1996;124: 681-2. 12. Wennberg JE, Goodman DC, Nease RF, Keller RB. Finding equilibrium in U. S. physician supply. Health Affairs 1993; 12:89-103. 13. Bateman TS, Zeithaml CP. Management: function & strategy. 2nd ed. Homewood, IL: Irwin, 1993. 14. McMurray JE, Schwartz MD, Genero NP, Linzer M. The attractiveness of internal medicine: a qualitative analysis of the experiences of female and male medical students. Society of General Internal Medicine Task Force on Career Choice in Internal Medicine. Ann Intern Med 1993;119:812-8. 15. Sanderson SC. Reengineering is not for the timid. AAMC Reporter 1996;5:1-4. 16. Lewis JE. Academic departments of internal medicine in the 1990s. Am J Med 1994;97:I-VI. 17. Langdon LO, Toskes PP, Kimball HR. Future roles and training of internal medicine subspecialists. American Board of Internal Medicine Task Force on Subspecialty Internal Medicine. Ann Intern Med 1996;124:686-91. 18. Weber KT. Exploring common ground (editorial). Hosp Pract 1995;29:11-2. 19. Herron GS. Vascular aneurysms: a side-splitting affair. Cardiovasc Res 1996;31:224-30.
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20. Weber KT, Sun Y, Katwa LC, Cleutjens JPM. Connective tissue: a metabolic entity? J Mol Cell Cardiol 1995,27:10720. 21. Weber KT, editor. Mysteries in internal medicine. Columbia, MO: University of Missouri Health Sciences Center, Department of Internal Medicine, 1996. 22. Ways M, Kroenke K, Umali J, Buchwald D. Morning report.
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A survey of resident attitudes. Arch Intern Med 1995;155: 1433-7. 23. Barzansky B, Friedman CP, Arnold L, et al. A view of medical practice in 2020 and its implications for medical school admission. Acad Med 1993;68:31-4. 24. Greenlick MR. Educating physicians for population-based clinical practice. JAMA 1992;267:1645-8.
ur coming together on the occasion of this plenary session offers us a unique opportunity to address issues of major concern to departments of internal medicine. Challenging issues that have arisen as a result of health care reform that is sweeping this nation. And what began as reform, directed at controlling health care financing, has culminated in a revolution that has affected health care delivery, medical student and resident education, and research. A revolution that has mandated revisions in department structure and operation. My purpose will be to focus on department restructuring. I would hasten to add that although necessary, restructuring must not occur at the expense of major missions in patient care, education, and research. Indeed, in today's climate ot reform, where the potential for innovation abounds, departments have the opportunity to enhance on these missions. I will address the topic of department restructuring mindful of the Council on Graduate Medical Education's fourth report to Congress and the Department of Health and Human Services.t In this report the Council on Graduate Medical Education indicated a stated goal to be the following: "All primary care shortage areas should be eliminated and disparities between metropolitan and non-metropolitan distribution of physicians should be reduced." It is my firm belief that planning and implementation of department restructuring must simultaneously take into account the needs of our
O
From the Department of Internal Medicine,Universityof Missouri Health SciencesCenter. Submittedfor publicationOct. 21, 1996; revisionsubmittedOct. 21, 1996; accepted Oct. 21, 1996. Reprint requests: Karl T. Weber, Universityof MissouriHealth SciencesCenter,Departmentof InternalMedicine,IVlA432Medical SciencesBldg., Columbia,MO 65212. J Lab Clin Med 1997;129:273-80. Copyright© 1997by Mosby-YearBook,Inc. 0022-2143/97 $5.00 + 0 5/1/78951
society--most important, the provision of high-quality care to the medically underserved populations of this country. This may seem far-fetched to academic health centers consumed by a doomsday attitude, where maintaining "vital signs" is the overriding priority and self-preservation transcends innovation and altruism. Shedding this perspective for a vision that extends beyond expressways to roads less well traveled may address both survival and success. THE CHALLENGE: HEALTH CARE REFORM
For the past decade departments of internal medicine throughout this land have heard the shrill warning call of our federal government's klaxon-prepare for health care reform! From the American Board of Internal Medicine, Association of American Medical Colleges, and American College of Physicians clarions were sounded summoning departments-react to these changing times, where managed care and capitation are rapidly replacing indemnity plans and fee-for-service medicine! The collective cacophony heralds a need to reorganize department structure. Does this mean departments should operate in a vertical or horizontal mode? Are we upright or supine? Given these uncertain times, a concern for department viability has arisen in some quarters. Senior statesmen festooned crepe at department doorways with inflammatory rhetoric to gain attention. "Internal medicine may be in its twilight because it has failed to address the shortage of primary care physicians by training more general internists. ''2 "We cannot continue to train the old-fashioned internist... We're dying. What the nation wants is primary care physicians, and that is what training programs must produce. ''3 " . . . we seem to be losing the battle in internal medicine in the medical school itself.''4 Perhaps our interest in programmed cell death, or apoptosis, has brought to the fore concepts of a "death wish" with death promoter effector pathways. Are departments of internal medicine about to disappear? Are we upright or supine? 273
274
J Lab Clin Med March 1997
Presidential Address
DEPARTMENTS OF INTERNAL MEDICINE Clinical Services
Vertical Integration: Interdepartment Service Lines
1
2
3
Fig. 1. Example of vertical integration between three departments.
PATIENT CARE: UPRIGHTOR SUPINE? In providing patient care in an ever-expanding managed care/capitated environment, departments must reorganize. The traditional independent mode of operation must be broadened to include coordinated, interdepartmental service lines--vertical integration within an academic health center (Fig. 1), and integrated intradepartmental services between divisions that eliminates redundancies and fragmentation-horizontal integration that blurs divisional boundaries (Fig. 2). Each department must find its own formula for success based on its strengths, the patient population it serves, and its geographic location. Nonetheless operating in both a vertical and horizontal mode, upright and supine, seems sensible. Success in a managed care/capitated environment depends on several well-known factors, which need reemphasis. First, an ability to win contracts and attract, then retain, patients. Second, an ability to manage care and optimize expenditures within a capitated payment schedule, where each component of health care delivery has become a cost center. These factors mandate the need for a coordinated, large medical group--an alliance of hospitals and physicians--that can joint venture and negotiate, have the ability to continually innovate, coordinate the continuum of care, monitor quality of care, and enact agreements in an effective and efficient manner.
A network of primary care providers is the foundation on which to build and achieve these objectives. This network includes general practitioners, family practitioners, general internists, and pediatricians, each of whom reside within an academic health center and its neighboring communities. It is this network that will manage the full continuum of patient care. It is mandatory that there be a culture of cooperation and common purpose--a single-minded attitude toward patient care in keeping with a collaborative, multidisciplinary group practice. This attitude must be operative within the academic health center and its partners in the community. Department chairs must foster this attitude and promote unified ownership in patient care, effective integration at all levels, and productive use of specialists. An attitude of entitlement, or sitting at home awaiting the referral, will lead to the refrain: "splish, splash, I'm taking a bath." In a culture of mutual education specialists must optimize the practice and education of primary care providers. To optimize patient care specialists must share certain technologies with these partners. There must exist the potential for cross-fertilization between specialists and generalists in an innovative system of care. 5 Departments of internal medicine must serve as guardians to their specialists: promoting their integration and effective use as a network of service lines within the academic health center,
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Presidential Address
275
DEPARTMENTS OF INTERNAL MEDICINE Clinical Services Horizontal Integration: Intradepartmental Services
Fig. 2. Example of horizontal integration between division within department.
establishing practice guidelines for specialists in the form of critical pathways, short stay, observation units, and guarding against antispecialist sentiment that would suggest these highly trained physicians are simply technology-driven and short on cognitive skills. Can all this be accomplished while meeting society's need to reduce health care shortage areas? What is the magnitude of the underserved population? Every state in the United States has health care shortage areas--both urban and rural. According to 1995 data of the Shortage Designation Branch of the Bureau of Primary Health Care, 6 there are a total of 2795 primary care shortage areas in the United States, and of these more than two thirds (1845) are nonmetropolitan. According to the Office of Rural Health Policy more than 50 million Americans live in rural areas, of whom nearly one hall 22.5 million, are medically underserved. 6 Only 9% of our nation's physicians practice in rural communities. The Federal Register identifies both underserved and served rural and urban counties within each state. From data found in the 1995 Federal Register7 the density of rural to urban shortage counties was determined by taking the ratio of rural underserved to urban underserved counties in each state. Densities were then subdivided into relative densities termed: none to low (ratio 0 to 1.0), found in 10 states; mild (ratio 1.1 to 1.99), present in 9 states; moderate (2.0 to
6.0), in 21 states; and severe (>6.0), found in 8 states. Rural underserved counties, represented by a ratio >1.1, predominate in 38 of the continental states. The same is true for Alaska and Hawaii. The density of rural underserved counties, again defined as the ratio of rural to urban underserved counties of >1.1, predominates in states located in the central, southeastern, and western regions of the United States. In the northeastern region urban underserved counties predominate. Fifteen states have been assumed to comprise the Central Region of the United States. Four of these states have a severe (>6.0) rural shortage problem; seven states a moderate (2.0 to 6.0) rural shortage problem, and three states a mild (1.1 to 2.0) rural shortage problem. Among central states Missouri has a ratio of rural to urban underserved counties of 5.4, representing a moderate density. It therefore could be considered representative of the rural shortage problem in the central region. There are 115 counties in Missouri; 64 are underserved, and of these 84% are rural counties. Missouri has 10,633 licensed physicians, with 9100 (86%) practicing in urban counties; only 1533 (14%) practice in nonmetropolitan areas, s The University of Missouri Health Sciences Center is located in the city of Columbia situated more or less in the center of the state. We have used a "hub and spoke model" to develop an integrated health care network that addresses both our patient care mission and our
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state's underserved rural counties. The model spans a 100-mile radius of Columbia and represents an academic health center without "walls." Each "hub" site has a hospital and is not designated an underserved county. We have already or are developing affiliations with these hospitals. At these hubs we provide outreach services for neighboring underserved counties that represent "spokes" served by each hub. Most spoke sites are within 30 miles of a hub hospital. The department of internal medicine initiated an outreach program in 1991. It drew on entrepreneurs at all levels, each of whom were willing to share risk in implementing this program, not the least of which included driving to these sites on a weekly basis. We began with one site. Over ensuing years our program has grown to include 10 hubs, where our specialties provide sought-after services. A specialist physician and nurse visit each hub on a regular basis, where they render scheduled, consultative services and interact with referring primary care providers. Our medical center's practice plan has developed affiliations with primary care providers within the hub and spoke model. In some cases the practices of primary care providers have been purchased, and these physicians formally integrated into our practice plan and faculty in internal medicine. The department has already placed and will continue to strategically place graduating residents at these sites, where they serve as general internists. These graduates are members of our faculty, our medical center's practice plan, and our affiliated network of physicians. Our medical school's federally and privately funded telemedicine program links our academic health center to these hubs in an efficient and economic manner. It provides primary care physicians with consultative, radiologic, educational, and research services. It provides health access to rural areas in a culture of cooperation, common purpose, and mutual education. In addition to providing health care to rural underserved counties, it is our hope that these collective strategies meet several additional objectives: reduce the sense of isolation that primary care providers at underserved rural shortage areas may experience and foster recruitment and retention of primary care providers at these sites. 6'9 The Bureau of Health Professions estimates that 2183 physicians are needed to remove all designated nonmetropolitan shortage areas. 6 However, if our target is 1 primary care physician for every 2000 people, then a total of 5257 such physicians are needed, suggesting that we will not have a surplus of primary care providers for some time to come.
What about specialists in Missouri? Is there a surplus or rather a maldistribution? Our 10 hub and spokes vary in size based on population served: four are large, serving a population of 90 to 120,000, three are medium, with a population of 50 to 60,000, and three are small, serving a population of 30 to 40,000. The total population served is approximately 700,000. Based on health maintenance organization staffing patterns, physician workforce requirements were estimated by Weiner. 1° This included the number of medical specialists needed to serve each population of 100,000. Based on these projections more than 100 medical specialists are needed in the underserved segment of mid-Missouri represented by our hub-spoke model. Some are already in place. 11 Others, practicing elsewhere, need to be recruited. Will they relocate? Will relocation only occur if their current metropolitan-based practice fails? 12 We plan to strategically place specialists at appropriate underserved sites, where they can either function as team leaders for patients with complex illnesses and specialized needs, or practice costeffective medicine when primary care providers are not in place. At some sites outreach specialty services alone will address community needs. EDUCATION: UPRIGHT OR SUPINE?
I now would like to focus on our second mission --education. The Central Society for Clinical Research includes 40 departments of internal medicine. The Society has much reason to be proud, not the least of which are its member medical schools recognized for their commitment to primary care. According to the most recent U.S. News & World Report survey (March 18, 1996:96-97), 8 of this country's top 15 primary care medical schools are members of the Central Society (Fig. 3). This notwithstanding, there is much to be done with the restructuring of medical education. Reform that addresses the broader mission of an academic health center to include societal needs. Should we be upright or supine? Targeted curricular reform has many components, not the least of which should address specific needs: residents, who will practice in underserved shortage areas as general internists, generalists, who serve as mentors at underserved sites, specialists, who represent tomorrow's scientists, consultants, and mentors at academic health centers. Curriculum reform must be accomplished in a cost-effective manner given likely reductions in funding available for graduate medical education. Advantages are offered by interdepartmental or vertical integration--a culture of mutual education--
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PRIMARY-CARE SCHOOLS 1. University of Washington 2. University of Massachusetts at Worcester 3. Oregon Health Sciences University 3. University of New Mexico 5. University of California at San Francisco 6. University of Missouri at Columbia 7. Southern Illinois University at Springfield 8. University of Iowa 9. Michigan State University 10. University of Kentucky 1 1. University of Minnesota at Duluth 12. Medical College of Wisconsin 13. Univ. of Colorado Health Sciences Center 14. East Carolina University 15. University of Kansas Medical Center US News & World Report, March 18, 1996 Fig. 3. Ranking of primary care medical schools by U. S. News & World Report (March 18, 1996:96-97). Schools representing membership in Central Society for Clinical Research are highlighted (Copyright 1996, U. S. News & World Report. By permission).
wherein a sharing of core topics independent of clinical training is promoted. Epidemiology, biostatistics, ethics, and principles of molecular biology are examples of such economy of scale. Since 1991 our department of internal medicine has operated with a matrix model. Managers in this model include program directors, or associate chairs for clinical affairs, education, and research, that interact with each division, and functional directors, more traditional division directors. Our associate chair of education, for example, is able to coordinate and implement curriculum reform across divisions, an example of intradepartmental or horizontal integration. A matrix structure is a hybrid form of organization in which functional and program forms overlap. 13 It allows for coordination across functions in business units when the environment is complex and challenging. It balances power and emphasis between program and function. It allows for consolidation of costs and a rapid response to marketplace demands. Managers must collaborate with one another while they manage. Faculty must accommodate to each set of managers. Chairs must delegate authority and responsibility to both program and functional directors. Matrix is a process--a method of operation--it represents a department's anatomy. Its physiology allows information to flow throughout the organization; its psychology determines the at-
titudes of faculty and how they modify their behavior and priorities in responding to reform. Success in a matrix model is largely based on how faculty embrace such an operational structure and the effectiveness of its managers. Department chairs and medical schools may need to modify their behavior including criteria for promotion or tenure if they placed undue emphasis on independence, an attitude that isolates faculty and emphasizes egocentricity at the expense of the enterprise. An attitude that may explain why faculty viewed patient care as an intrusion and education as an imposition. Some, short on clinical skills, would hide behind a mantle of arrogance to overcome their insecurity. A sparsity of role models is not a surprising outcome in such an environment. 14 Others would now suggest academicians "are not necessarily team players. ''15 Patient care and education are not interruptions of our work; they are our work, and so is the health of the enterprise. Training residents for careers as primary care internists should be commensurate with the current practice environment and their eventual practice setting. Programs must have the flexibility to individualize resident training based on the where and what of their future practice. 16 The where addresses whether generalists will practice in urban or rural locations and whether either site is served or under-
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served. Ambulatory care and in-hospital training at such sites must be provided. Training in the principles of managed care and capitated services--that is, cost-effective delivery of high-quality care--is a requisite in either case. Graduating residents must be competent, confident, and compassionate physicians wherever they practice medicine. The what of a general internist's training at underserved sites may need to consider basic elements of gynecology, ophthalmology, otorhinolaryngology, orthopedics, pediatrics, physical medicine and rehabilitation, psychiatry, and family medicine. Yes, there is much to be learned from our colleagues in family practice. Toward these ends the hub and spoke model serves as an educational network. Such vertical integration with community with on-site primary care providers as educators can be incorporated into new curricula. Communities may wish to share in the costs of resident training. Such partnering enables a training program to draw up an individualized curriculum for its residents and to provide generalists to sponsoring underserved communities in accordance with need. Horizontal or intradivisional integration is needed for overlapping segments of specialist training such as future academicians dedicated to the basic sciences and clinical investigation. 17 Even more broadly speaking, horizontal integration should include a tearing down of barriers between specialties seeking common pathophysiologic expressions and mechanisms of disease. 18 For example, polycystic kidney disease is often associated with intestinal diverticuli, myxomatous degeneration of heart valve leaflets, and vascular aneurysms. It likely reflects a single gene defect and common disease process of unbridled proteolytic digestion of structural proteins by matrix metalloproteinases. 19 Tissue repair gone awry, expressed as a progressive interstitial fibrosis, is another. It can explain kidney, lung, heart, and liver failure in diverse settings, where collagen turnover by phenotypically transformed fibroblast-like cells (myofibroblasts) is abnormal and governed by locally generated peptides and polypeptides. 2° Faculty committed to the enterprise represent a creative wellspring that can be tapped in revamping and revitalizing educational programs for residents and students. A problem-based learning curriculum was recently implemented at our institution and has done much to encourage and accelerate student use of deductive reasoning; its principles can be used effectively in house staff training. A successful tool at our medical center is case-based medical myster-
ies with the detective, an internist, serving as integrator of diverse clues. 21 Educational reform must include Morning Report 22 and Professors Rounds, stalwart sessions of training programs. Irrespective of whether they take place in a hospital or ambulatory care setting, these sessions provide an opportunity to enhance resident and student understanding of pathophysiology and to develop reasoned mature judgement while mindful of health care costs. In this connection the importance of a skillfully obtained history and physical examination cannot be overstated. These principles, although self-evident, require that chairs and mentors spend less time "in the air," lest he or she leave the impression "if he doesn't care, why should I?" It's far more important in these times of reform to be locally available, prepared, and appreciated than to fulfill egocentric needs of national and international recognition. RESEARCH: UPRIGHT OR SUPINE?
Should a department's revamped research mission operate upright or supine? Through effective interdepartmental and intradepartmental collaboration and vertical and horizontal integration, new knowledge will emerge. Who better than departments of internal medicine to lead the way in bridging advances in molecular biology and genetics with the practice of medicine? We must fulfill this expectation of scholarly leadership. It is an expectation we cannot shy away from. It is essential to our viability. In my judgment the time is propitious for academic health centers to broaden their research mission and reach out. Self-contained and self-served no longer apply. Reform must include public service within their state and our nation. Centers need to assume a more active role in addressing societal needs and seeking innovative solutions to critical social issues. The medically underserved populations of our country, both rural and urban, represent such a problem. We must further recognize that research and innovation can be a friend o f cost containment.
Research topics a r e m a n y . 12'23'24 They should be population-based and patient-centered in nature with the integrated health care network to develop community-based services for disease prevention, effective delivery of health care for chronic illness, outcomes research to improve the scientific basis of everyday practice of medicine and to better organize care to produce improved outcomes at lower cost, practice guidelines for the use of new or established treatments, relative cost/benefit ratios of alternative technologies compared with health needs of the population served and the ability of the system to
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use new technology, work force needs in caring for populations served within the region, and education of involved populations regarding health and wellbeing. No matter what the scope of such a program is, the actual needs of the community must be determined with active involvement of community health care professionals and public leaders. Involvement that promotes self-help and empowerment rather than promoting dependency for their patient or their community. SUMMARY
In closing, I would reiterate that with the inevitable restructuring of departments of internal medicine, now is the time to develop innovative, interdisciplinary strategies to manage across boundaries. Strategies of vertical and horizontal integration within an academic health center and its alliance with the communities it serves. Strategies that will enhance our missions in patient care, education, and research. Recreate the environment that will once again allow nature to flourish. During this time of reform we are not strapped with sustaining the status quo. Opportunities for innovation abound. Innovation demands an ability to reallocate and adapt. Abandon old paradigms. Seize the occasion to reformulate, restructure, revitalize, and revamp--to write a new chapter. We are limited only by our creative potential and entrepreneurial spirit, or willingness to take risk. I ask you, who better than academic health (:enters to succeed in managed care? Corporate relationships between medical school and hospital already exist, and with innovative restructuring seamless delivery of high-quality care is a reasonable expectation. Seize the opportunity. I ask you, who better than departments of internal medicine to provide innovative answers to seamless delivery of primary and specialty care? But vision begets responsibilities. In formulating plans of reform we must rise to the challenge of solving critical societal needs. Medically underserved populations should be targeted for high-quality health care. Community-based patient-centered programs of education, research, and preventive medicine must be provided. Research can be the friend of cost containment. In placing a premium on synergies that will increase our potential, our productivity, and effectiveness in a culture of cooperation, common parpose, and mutual education, new knowledge for the twenty-first century will emerge and of which we can be justifiably proud. It will guarantee our viability. It will be our legacy.
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REFERENCES
1. Council on Graduate Medical Education. Fourth Report to Congress and the Department of Health & Human Services Secretary: Recommendations to Improve Access to Health Care Through Physician Workforce Reform. Washington, DC: US Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, 1994. 2. Petersdorf RG, Goitein L. The future of internal medicine. Ann Intern Med 1993;119:1130-7. 3. Gordon A, American Board of Internal Medicine. Report of the 1993 ABIM Summer Conference. The General Internist: Who, What, Where, When, How--And Why! Philadelphia: American Board of Internal Medicine, 1993:71. 4. Leavey G, American Board of Internal Medicine. Report of the 1993 ABIM Summer Conference. The General Internist: Who, What, where, When, How--And Why! Philadelphia: American Board of Internal Medicine, 1993:72. 5. Saultz JW. Reflections on internal medicine and family medicine. Ann Intern Med 1996;124:600-3. 6. Konrad TR. The problem of shortages of physicians and other health professionals in rural areas: empirical evidence and policy recommendations. In: American Council on Graduate Education, editor. Geographic distribution of physicians in rural and urban uderserved areas. Washington, DC: US Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, 1997 (in press). 7. Department of Health and Human Services HR and SA. Lists of designated primary medical care, mental health, and dental health professional shortage areas. Federal Register 1995;190:51518-655. 8. Rural Health Initiatives Committee. Rural Health Primer. Columbia, MO: University of Missouri, 1994. 9. Anonymous. Rural primary care. American College of Physicians. Ann Intern Med 1995;122:380-90. 10. Weiner JP. Forecasting the effects of health reform on US physician workforce requirement. Evidence from HMO staffing patterns. JAMA 1994;272:222-30. 11. Weiner JP. Internal medicine at the crossroads: training subspecialists for the next century. Ann Intern Med 1996;124: 681-2. 12. Wennberg JE, Goodman DC, Nease RF, Keller RB. Finding equilibrium in U. S. physician supply. Health Affairs 1993; 12:89-103. 13. Bateman TS, Zeithaml CP. Management: function & strategy. 2nd ed. Homewood, IL: Irwin, 1993. 14. McMurray JE, Schwartz MD, Genero NP, Linzer M. The attractiveness of internal medicine: a qualitative analysis of the experiences of female and male medical students. Society of General Internal Medicine Task Force on Career Choice in Internal Medicine. Ann Intern Med 1993;119:812-8. 15. Sanderson SC. Reengineering is not for the timid. AAMC Reporter 1996;5:1-4. 16. Lewis JE. Academic departments of internal medicine in the 1990s. Am J Med 1994;97:I-VI. 17. Langdon LO, Toskes PP, Kimball HR. Future roles and training of internal medicine subspecialists. American Board of Internal Medicine Task Force on Subspecialty Internal Medicine. Ann Intern Med 1996;124:686-91. 18. Weber KT. Exploring common ground (editorial). Hosp Pract 1995;29:11-2. 19. Herron GS. Vascular aneurysms: a side-splitting affair. Cardiovasc Res 1996;31:224-30.
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20. Weber KT, Sun Y, Katwa LC, Cleutjens JPM. Connective tissue: a metabolic entity? J Mol Cell Cardiol 1995,27:10720. 21. Weber KT, editor. Mysteries in internal medicine. Columbia, MO: University of Missouri Health Sciences Center, Department of Internal Medicine, 1996. 22. Ways M, Kroenke K, Umali J, Buchwald D. Morning report.
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A survey of resident attitudes. Arch Intern Med 1995;155: 1433-7. 23. Barzansky B, Friedman CP, Arnold L, et al. A view of medical practice in 2020 and its implications for medical school admission. Acad Med 1993;68:31-4. 24. Greenlick MR. Educating physicians for population-based clinical practice. JAMA 1992;267:1645-8.