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Public policy and patient care: Implications for internal medicine
MEDICINE,
SCIENCE AND SOCIETY
Public Policy and Patient Care: Implications for Internal Medicine JEREMIAH
I nal medicine
A. BARONDESS,
ssues concerning manpower for the future in interare critical for several reasons. First, they reflect a generic type of activity that has already become important and will become more so; that activity is the formulation of policy in health matters by people and agencies outside of medicine, chiefly in the federal government. In relation to internal medicine manpower a de facto partnership has been established between the public and private sectors in the form of the National Study of Internal Medicine Manpower (NASIMM), generated by the Association of Professors of Medicine and funded by the Federated Council for Internal Medicine, on the one hand, and the Graduate Medical Education National Advisory Committee of the Department of Health and Human Services (GMENAC) on the other. The activities of GMENAC [a public sector enterprise) are based in part on data being assembled by the NASIMM study (a private sector effort) and in part on the herculean labors of its own membership and advisory bodies, all from the private sector. This kind of cooperative effort in health policy development is something we have to promote, to become expert in and to be willing to contribute to if governmental efforts in health are to be enlightened and if public policy is to be tempered with the professional insights it requires. We must learn to look at federal and state policy initiatives without polarizing the debate between “our” system and “theirs”; we are going to have to see the governmental system, at least as it relates to policy development, as “ours” to a considerably greater degree than in the past, and to get into it in a broader manner, earlier in the development of issues, and with a mix of data-based positions and concerns for the individual sick, for the medical educational and training systems and for the research enterprise; all these positions will have to be
M.A.C.P.
argued clearly, rationally and in an articulate manner. A second general point about these issues is that, like a number of others, they cannot be left unattended by us; they will not go away, and they will not remain unchanged: something will certainly be done in relation to them. We in medicine should make ourselves as knowledgeable as possible and should try to contribute responsibly to their resolution, both by government and by our own internal governance apparatus. If we do not, the policy decisions will be made anyway, without us, without crucial insights from the profession itself. The issues in public policy as they bear on internal medicine may be approached through a set of relatively straightforward questions. The first of these, and the most compelling, is What are the needs of the patients? These can be assembled fairly readily: patients need access to the system and they need care, and they need both of these at a fiscally rational level. All three needs are intertwined, and all must be addressed. The access issue has been approached through increasing the number of physicians, by efforts to broaden the types of physicians available and by reducing financial barriers to care. This has been seasoned with the appropriate view that the most coherent access to the care system is through a personal physician who not only provides that function in a general sense but who is also himself a source of broad care which is characterized also by continuity over time and by a personal relationship with the patient. Views of the adequacy of the access system vary widely; there are clearly geographic areas in which physician density is low, but some studies, notably that of Aiken and her group [l], suggest that the bulk of the population do have reasonable access to care or will shortly. In any case, the
From the Department of Medicine, The New York Hospital-Cornell Medical Center. This was presented in part in a panel discussion “What is an internist? Public policy implications.” at the Annual Session, The American College of Physicians, New Orleans, Louisiana, April 21, 1980. Requests for reprints should be addressed to Dr. reremiah A. Barondess, Department of Medicine, The New York Hospital-Cornell Medical Center, 449 East 68th Street, New York, NY 16621.
February 1981 The American Journal of Medicine
Volume 70
223
MEDICINE, SCIENCE AND SOCIETY-BARONDESS
problem of geographic maldistribution of physicians is unlikely to be solved through attention to numbers or probably to financing: satellite facilities, transportation networks and other efforts to bring patients and clinical care loci together are more promising approaches. In relation to the kind of physician providing the access point, internists have long represented the largest segment with the characteristics mentioned earlier. The optimal mix within internal medicine has generated lively debate recently. It is probably true that subspecialists are somewhat more likely than generalists to settle in areas with larger populations, with a larger physician referral base and with greater access to hospitals and high technology, although it appears that, in response to saturation of urban centers, young subspecialists are now moving out of the cities, into the suburbs and beyond. Another factor is the higher fee structure of subspecialists. These potential constraints in access are to be balanced against the contribution subspecialists make to the general medical care of their patients. Data are just beginning to appear on this point from the Mendenhall study [Z], and they appear to confirm the impression that considerable primary care is rendered by subspecialists. Other efforts are being made to address the geographic distribution problem through such programs as the National Health Service Corps and the WAMI program of the University of Washington, which exposes students and residents to small-town health facilities. The success of ventures like this one remains to be determined, just as the influence of the generalist/subspecialist mix on access awaits more information. The needs of patients relative to care are complex and should dominate policy decisions. I would submit the following list of characteristics to be striven for in the care of our patients: (1) Effkiency in translation of the presenting syndrome to identification of its cause. Efficiency implies both accuracy of diagnosis and effective, knowledgedirected use of the technology in pursuit of the diagnosis and in management. (2) Comprehensiveness, including not only the likelihood of having most of the problems that present over the course of time handled effectively by the personal physician, but also the likelihood that that physician will be able to approach diagnosis and therapy in a clinically eclectic fashion, unconstrained by his or her particular or special interests. (3) State-of-the-art care, in a technical sense. I do not mean to infer that every physician should be able to offer each patient ultimate expertise in every area, but rather that each patient should have a reasonable prospect of access to whatever of current knowledge and expertise is germane to his problem, either from his own physician or, through that physician, from others in the system.
224
February 1981
The American Journal of Medicine
(4) Samaritan functions of the doctor, that is, those human support functions that are part of our traditional responsibility, part of what almost every patient needs to some degree, and which gave medicine a place of honor and respect in society long before physicians knew the causes or cures of anything. Science and technology have not relieved us of these responsibilities; on the contrary, they have heightened the need to remember that medical care is a human transaction.
(5) Cost restraint is another vital component of proper care, as is technologic restraint. These are linked to each other and also to the cognitive knowledge base of the physician. Data from the certifying examination of the American Board of Internal Medicine (Webster G; unpublished data] indicate this; that is, the aggregate costs incurred in working up the patient management problems are inversely related to scores on the multiple choice section of the examination, which is designed to measure cognitive types of information. There is a crucial message here for us, even though the data only tend to confirm what we have intuited for a long time, namely, the better informed the doctor the better the care, the more efficient the care, the less costly the care. (6) A final characteristic of good care, already mentioned, is appropriate referral. This is linked to all the other parameters previously referred to. The adjective “appropriate” is intended to indicate that referral should be a threshold phenomenon unless the doctor is to function simply as a triage station, that is to say that the personal physician should have the capacity and the intent to manage most of the problems of his patient over time. If the foregoing can be accepted as outlining the chief needs of patients, my second question is What are the characteristics of the system that should bear on policy determinations? I would offer these:
(11Medicine is complex, both in relation to diagnosis and management. Its complexity derives from its newfound science base and the technology derived from it. Since these will steadily increase in scope and complexity, medical practice will certainly become more complex in the future. (2) Primary care and the care of ambulatory patients are not simple transactions, but require considerable clinical expertise and sound judgment if major disease is to be recognized in its incipiency or, once recognized, managed so as to forestall hospitalization to the extent possible, and if less threatening problems are to be identified and handled deftly and appropriately. Such expertise and judgment must frequently be brought to bear with substantially less technologic backup than is available for hospitalized patients.
Volume 70
MEDICINE.
(3) The ambulatory patient population cared for in the practice of general internal medicine is characterized by a preponderance of major disease as is, of course, the inpatient segment of practice. Most of these ambulatory patients have major, potentially life-limiting, chronic diseases, but acute exacerbations, complications or changes in course are common, as are superimposed, discomfiting but less serious disorders. Presenting complaints based primarily on emotional factors are, in my experience, less common than was formerly thought. Very large numbers of the elderly are also included and, whatever their problems, call for sensitive and sophisticated care. Thus, between pri-
mary and tertiary care lie an enormous number of patient problems which are neither, but which, in intensity and complexity, lie between discomfiting but nonthreatening minor disorders on the one hand and disastrous illness on the other. Internists handle an enormous segment of this secondary care demand and, because of the depth of their training, are particularly qualified to do so-in addition to the primary and tertiary care they render. The dimensions of this contribution to patient care need to be quantified. In my view the secondary care needs of the population are likely to be at least as great as those for primary care and hold considerable potential for ongoing disability, hospitalization and the generation of enormous further costs if not handled appropriately. (4) Tertiary care is an important component of the internist’s activities; this applies to general internists, who conduct a substantial segment of the adult hospital care in this country, as well as to subspecialists. (5) All patients present with undifferentiated problems when they access the system. Diagnostic eclectism is, therefore, a virtue and diagnostic skill a necessity. We should remember that major diseases frequently present with minor symptoms. Now, against
all that, my third question:
What is
unique about internists? First, they embrace
primary, secondary and tertiary care broadly and effectively, and thereby address the bulk of nonsurgical needs of all but the pediatric population. The combination of breadth and depth offered by the internist is unique and is well matched to the majority of clinical problems requiring medical care, most of which either reflect the presence of important disease or require sophisticated judgments about the nature of the underlying process. Thus, the internist is able to manage most of the problems presented to him and to refer the patient in a highly selective manner to other specialists or to subspecialists. To these service capacities he adds the ability to manage most of the minor discomfiting problems presented by his patients, and to sort them from major disease with an expertise derived from his training in depth across a broad range of problems. He fills broad consultant
February
SCIENCE
AND
SOCIETY--BARONDESS
functions, both for his colleagues in internal medicine and those in other specialties. In addition he serves vital educational and training functions, the latter relative not only to the needs of residents in internal medicine programs, but to trainees in other fields as well. Further, he contributes to medical advance in his field through basic or clinical investigations and, importantly, is able to bring advances to the care of his patients with minimal lag. Yet further, he practices in a manner that welds clinical expertise and the technology available to the human support functions of the physician, that is, he attends to the needs of both disease and illness, striving to meet the old admonition to care for the whole patient, and he does this with respect for both the science/ technology and the human sides of the equation, to a substantial degree.
What should be done, in terms of public policy? Policy judgments should be based on careful assessment of the needs of patients, the nature of the science and technology base of medicine, the relevant characteristics of the system and the unique capacities of internists. Carefully assembled, concept-based policies will serve the public better in the long run than policies oriented primarily around fiscal pressures or around the view that general medical care, particularly as it relates to ambulatory patients, is simple, straightforward or concerned primarily with benign, self-limiting disorders. In my view, the bulk of the nonsurgical care of adults will continue to be best addressed by internists because their experience and training fit them best to the mix of clinical challenges presented by the ambient population and because training in depth is more likely to forestall obsolescence in clinical care patterns and to minimize the lag between discovery and clinical application. The cost factor should, of course, not be ignored in planning, but aggregate costs are by themselves inadequate measures. I have mentioned the ABIM (American Board of Internal Medicine) data indicating a relationship between cognitive knowledge and cost-effectiveness of care. In addition, I am concerned with another, higher cost that may be incurred if we do not train for deep competence in primary and secondary care-and that is a hidden cost in adverse patient outcomes. Data will be hard to assemble on this point, but they should be sought, since health policy clearly must be arranged primarily to protect and, if possible, to enhance patient outcomes to the extent possible. How many subspecialists should we train, and how many generalists? This difficult question should be addressed in a data-based manner related to the needs of patients, of the educational enterprise in medicine and of the research effort. The need for subspecialists will also be related to decisions concerning family practice vis-a-vis general internal medicine: if the balance shifts in the direction of training more family practitioners, the need for subspecialist internists will, I would think, be increased as more referrals will likely
1991
The American Journal of Medicine
Volume 70
225
MEDICINE. SCIENCE AND SOCIETY-BARONDESS
be made, whereas if we train more general internists, fewer referrals will be likely. In either case the aggregate costs of this segment of the system are likely to be about the same. Data on referral patterns in this connection are sorely needed. In summary, the contributions of the internist to patient care are unique in the mix of breadth and depth they present. This immense resource must be protected and, in fact, enhanced if clinical practice in the future
226
February 1981 The American Journal of Medicine
is to match the needs of the population in an optimal way. REFERENCES 1. Aiken LH, Lewis CE, Craig J, Mendenhall RC. Blendon RJ, Rogers DE: The contribution of specialists to the delivery of primary care. N Engl J Med 1979; 300: 1363. 2. Girard RA, Mendenhall RC, Tarlov AR, Radecki SE, Abrahamson S: A national study of internal medicine and its specialties. I. An overview of the practice of internal medicine. Ann Intern Med 1979; 90: 965.
Volume 70
SCIENCE AND SOCIETY
Public Policy and Patient Care: Implications for Internal Medicine JEREMIAH
I nal medicine
A. BARONDESS,
ssues concerning manpower for the future in interare critical for several reasons. First, they reflect a generic type of activity that has already become important and will become more so; that activity is the formulation of policy in health matters by people and agencies outside of medicine, chiefly in the federal government. In relation to internal medicine manpower a de facto partnership has been established between the public and private sectors in the form of the National Study of Internal Medicine Manpower (NASIMM), generated by the Association of Professors of Medicine and funded by the Federated Council for Internal Medicine, on the one hand, and the Graduate Medical Education National Advisory Committee of the Department of Health and Human Services (GMENAC) on the other. The activities of GMENAC [a public sector enterprise) are based in part on data being assembled by the NASIMM study (a private sector effort) and in part on the herculean labors of its own membership and advisory bodies, all from the private sector. This kind of cooperative effort in health policy development is something we have to promote, to become expert in and to be willing to contribute to if governmental efforts in health are to be enlightened and if public policy is to be tempered with the professional insights it requires. We must learn to look at federal and state policy initiatives without polarizing the debate between “our” system and “theirs”; we are going to have to see the governmental system, at least as it relates to policy development, as “ours” to a considerably greater degree than in the past, and to get into it in a broader manner, earlier in the development of issues, and with a mix of data-based positions and concerns for the individual sick, for the medical educational and training systems and for the research enterprise; all these positions will have to be
M.A.C.P.
argued clearly, rationally and in an articulate manner. A second general point about these issues is that, like a number of others, they cannot be left unattended by us; they will not go away, and they will not remain unchanged: something will certainly be done in relation to them. We in medicine should make ourselves as knowledgeable as possible and should try to contribute responsibly to their resolution, both by government and by our own internal governance apparatus. If we do not, the policy decisions will be made anyway, without us, without crucial insights from the profession itself. The issues in public policy as they bear on internal medicine may be approached through a set of relatively straightforward questions. The first of these, and the most compelling, is What are the needs of the patients? These can be assembled fairly readily: patients need access to the system and they need care, and they need both of these at a fiscally rational level. All three needs are intertwined, and all must be addressed. The access issue has been approached through increasing the number of physicians, by efforts to broaden the types of physicians available and by reducing financial barriers to care. This has been seasoned with the appropriate view that the most coherent access to the care system is through a personal physician who not only provides that function in a general sense but who is also himself a source of broad care which is characterized also by continuity over time and by a personal relationship with the patient. Views of the adequacy of the access system vary widely; there are clearly geographic areas in which physician density is low, but some studies, notably that of Aiken and her group [l], suggest that the bulk of the population do have reasonable access to care or will shortly. In any case, the
From the Department of Medicine, The New York Hospital-Cornell Medical Center. This was presented in part in a panel discussion “What is an internist? Public policy implications.” at the Annual Session, The American College of Physicians, New Orleans, Louisiana, April 21, 1980. Requests for reprints should be addressed to Dr. reremiah A. Barondess, Department of Medicine, The New York Hospital-Cornell Medical Center, 449 East 68th Street, New York, NY 16621.
February 1981 The American Journal of Medicine
Volume 70
223
MEDICINE, SCIENCE AND SOCIETY-BARONDESS
problem of geographic maldistribution of physicians is unlikely to be solved through attention to numbers or probably to financing: satellite facilities, transportation networks and other efforts to bring patients and clinical care loci together are more promising approaches. In relation to the kind of physician providing the access point, internists have long represented the largest segment with the characteristics mentioned earlier. The optimal mix within internal medicine has generated lively debate recently. It is probably true that subspecialists are somewhat more likely than generalists to settle in areas with larger populations, with a larger physician referral base and with greater access to hospitals and high technology, although it appears that, in response to saturation of urban centers, young subspecialists are now moving out of the cities, into the suburbs and beyond. Another factor is the higher fee structure of subspecialists. These potential constraints in access are to be balanced against the contribution subspecialists make to the general medical care of their patients. Data are just beginning to appear on this point from the Mendenhall study [Z], and they appear to confirm the impression that considerable primary care is rendered by subspecialists. Other efforts are being made to address the geographic distribution problem through such programs as the National Health Service Corps and the WAMI program of the University of Washington, which exposes students and residents to small-town health facilities. The success of ventures like this one remains to be determined, just as the influence of the generalist/subspecialist mix on access awaits more information. The needs of patients relative to care are complex and should dominate policy decisions. I would submit the following list of characteristics to be striven for in the care of our patients: (1) Effkiency in translation of the presenting syndrome to identification of its cause. Efficiency implies both accuracy of diagnosis and effective, knowledgedirected use of the technology in pursuit of the diagnosis and in management. (2) Comprehensiveness, including not only the likelihood of having most of the problems that present over the course of time handled effectively by the personal physician, but also the likelihood that that physician will be able to approach diagnosis and therapy in a clinically eclectic fashion, unconstrained by his or her particular or special interests. (3) State-of-the-art care, in a technical sense. I do not mean to infer that every physician should be able to offer each patient ultimate expertise in every area, but rather that each patient should have a reasonable prospect of access to whatever of current knowledge and expertise is germane to his problem, either from his own physician or, through that physician, from others in the system.
224
February 1981
The American Journal of Medicine
(4) Samaritan functions of the doctor, that is, those human support functions that are part of our traditional responsibility, part of what almost every patient needs to some degree, and which gave medicine a place of honor and respect in society long before physicians knew the causes or cures of anything. Science and technology have not relieved us of these responsibilities; on the contrary, they have heightened the need to remember that medical care is a human transaction.
(5) Cost restraint is another vital component of proper care, as is technologic restraint. These are linked to each other and also to the cognitive knowledge base of the physician. Data from the certifying examination of the American Board of Internal Medicine (Webster G; unpublished data] indicate this; that is, the aggregate costs incurred in working up the patient management problems are inversely related to scores on the multiple choice section of the examination, which is designed to measure cognitive types of information. There is a crucial message here for us, even though the data only tend to confirm what we have intuited for a long time, namely, the better informed the doctor the better the care, the more efficient the care, the less costly the care. (6) A final characteristic of good care, already mentioned, is appropriate referral. This is linked to all the other parameters previously referred to. The adjective “appropriate” is intended to indicate that referral should be a threshold phenomenon unless the doctor is to function simply as a triage station, that is to say that the personal physician should have the capacity and the intent to manage most of the problems of his patient over time. If the foregoing can be accepted as outlining the chief needs of patients, my second question is What are the characteristics of the system that should bear on policy determinations? I would offer these:
(11Medicine is complex, both in relation to diagnosis and management. Its complexity derives from its newfound science base and the technology derived from it. Since these will steadily increase in scope and complexity, medical practice will certainly become more complex in the future. (2) Primary care and the care of ambulatory patients are not simple transactions, but require considerable clinical expertise and sound judgment if major disease is to be recognized in its incipiency or, once recognized, managed so as to forestall hospitalization to the extent possible, and if less threatening problems are to be identified and handled deftly and appropriately. Such expertise and judgment must frequently be brought to bear with substantially less technologic backup than is available for hospitalized patients.
Volume 70
MEDICINE.
(3) The ambulatory patient population cared for in the practice of general internal medicine is characterized by a preponderance of major disease as is, of course, the inpatient segment of practice. Most of these ambulatory patients have major, potentially life-limiting, chronic diseases, but acute exacerbations, complications or changes in course are common, as are superimposed, discomfiting but less serious disorders. Presenting complaints based primarily on emotional factors are, in my experience, less common than was formerly thought. Very large numbers of the elderly are also included and, whatever their problems, call for sensitive and sophisticated care. Thus, between pri-
mary and tertiary care lie an enormous number of patient problems which are neither, but which, in intensity and complexity, lie between discomfiting but nonthreatening minor disorders on the one hand and disastrous illness on the other. Internists handle an enormous segment of this secondary care demand and, because of the depth of their training, are particularly qualified to do so-in addition to the primary and tertiary care they render. The dimensions of this contribution to patient care need to be quantified. In my view the secondary care needs of the population are likely to be at least as great as those for primary care and hold considerable potential for ongoing disability, hospitalization and the generation of enormous further costs if not handled appropriately. (4) Tertiary care is an important component of the internist’s activities; this applies to general internists, who conduct a substantial segment of the adult hospital care in this country, as well as to subspecialists. (5) All patients present with undifferentiated problems when they access the system. Diagnostic eclectism is, therefore, a virtue and diagnostic skill a necessity. We should remember that major diseases frequently present with minor symptoms. Now, against
all that, my third question:
What is
unique about internists? First, they embrace
primary, secondary and tertiary care broadly and effectively, and thereby address the bulk of nonsurgical needs of all but the pediatric population. The combination of breadth and depth offered by the internist is unique and is well matched to the majority of clinical problems requiring medical care, most of which either reflect the presence of important disease or require sophisticated judgments about the nature of the underlying process. Thus, the internist is able to manage most of the problems presented to him and to refer the patient in a highly selective manner to other specialists or to subspecialists. To these service capacities he adds the ability to manage most of the minor discomfiting problems presented by his patients, and to sort them from major disease with an expertise derived from his training in depth across a broad range of problems. He fills broad consultant
February
SCIENCE
AND
SOCIETY--BARONDESS
functions, both for his colleagues in internal medicine and those in other specialties. In addition he serves vital educational and training functions, the latter relative not only to the needs of residents in internal medicine programs, but to trainees in other fields as well. Further, he contributes to medical advance in his field through basic or clinical investigations and, importantly, is able to bring advances to the care of his patients with minimal lag. Yet further, he practices in a manner that welds clinical expertise and the technology available to the human support functions of the physician, that is, he attends to the needs of both disease and illness, striving to meet the old admonition to care for the whole patient, and he does this with respect for both the science/ technology and the human sides of the equation, to a substantial degree.
What should be done, in terms of public policy? Policy judgments should be based on careful assessment of the needs of patients, the nature of the science and technology base of medicine, the relevant characteristics of the system and the unique capacities of internists. Carefully assembled, concept-based policies will serve the public better in the long run than policies oriented primarily around fiscal pressures or around the view that general medical care, particularly as it relates to ambulatory patients, is simple, straightforward or concerned primarily with benign, self-limiting disorders. In my view, the bulk of the nonsurgical care of adults will continue to be best addressed by internists because their experience and training fit them best to the mix of clinical challenges presented by the ambient population and because training in depth is more likely to forestall obsolescence in clinical care patterns and to minimize the lag between discovery and clinical application. The cost factor should, of course, not be ignored in planning, but aggregate costs are by themselves inadequate measures. I have mentioned the ABIM (American Board of Internal Medicine) data indicating a relationship between cognitive knowledge and cost-effectiveness of care. In addition, I am concerned with another, higher cost that may be incurred if we do not train for deep competence in primary and secondary care-and that is a hidden cost in adverse patient outcomes. Data will be hard to assemble on this point, but they should be sought, since health policy clearly must be arranged primarily to protect and, if possible, to enhance patient outcomes to the extent possible. How many subspecialists should we train, and how many generalists? This difficult question should be addressed in a data-based manner related to the needs of patients, of the educational enterprise in medicine and of the research effort. The need for subspecialists will also be related to decisions concerning family practice vis-a-vis general internal medicine: if the balance shifts in the direction of training more family practitioners, the need for subspecialist internists will, I would think, be increased as more referrals will likely
1991
The American Journal of Medicine
Volume 70
225
MEDICINE. SCIENCE AND SOCIETY-BARONDESS
be made, whereas if we train more general internists, fewer referrals will be likely. In either case the aggregate costs of this segment of the system are likely to be about the same. Data on referral patterns in this connection are sorely needed. In summary, the contributions of the internist to patient care are unique in the mix of breadth and depth they present. This immense resource must be protected and, in fact, enhanced if clinical practice in the future
226
February 1981 The American Journal of Medicine
is to match the needs of the population in an optimal way. REFERENCES 1. Aiken LH, Lewis CE, Craig J, Mendenhall RC. Blendon RJ, Rogers DE: The contribution of specialists to the delivery of primary care. N Engl J Med 1979; 300: 1363. 2. Girard RA, Mendenhall RC, Tarlov AR, Radecki SE, Abrahamson S: A national study of internal medicine and its specialties. I. An overview of the practice of internal medicine. Ann Intern Med 1979; 90: 965.
Volume 70