Dr Bob posts on DB's Medical Rants an interesting reference to his paper in Journal of General Internal Medicine. Family physicians feel your pain, man ... and I agree with you that there remains a place for General Internal Medicine ... but ... here's what may be an odd concept: the General Internist as specialist in complex adult medicine .. just as the pediatrician could be positioned as a specialist in complex pediatric medicine.
Ever Since Family Medicine displaced "General Practice" many years ago - the identity of the "other" generalists (peds and IM) has certainly been threatened. Yes, yes ... this isn't the message of Dr Centor's paper ... he seems to be more concerned with pressure from the right -- the specialists. But I would argue that there exists some pressure from the left (FP) as well.
It is not uncommon that I call an Internist friend to ask for advice in a situation that involves a very complex adult problem. Why? Because in some cases, the training of an Internist simply prepares them better for handling such situations. A good generalist knows the boundaries of his/her skill -- and while most family physicians are capable of providing excellent care to children, adults, the elderly, and pregnant women -- there are some situations in which we are better off having the help of someone who specializes. "You are worth it" I tell my hesitant patients. They sometimes seem to wish I could do everything for them. I can't. This is why we have specialists.
Yet with their identities as "general adult medicine" physicians -- there is no good method for me to refer a patient to an Internist for consultation. Since they are primary care physicians - there is no "referring/consulting" physician relationship between Family Physicians and Internists (or Pediatricians) .. but I think that such an arrangement would be beneficial for all.
The "other" generalists may build a better understanding of what we do (many practicing internists and pediatricians didn't do a family medicine rotation in medical school) ... and we may learn not to be so threatened by them.
Our Mantra seems to be "we provide the same care as they do." Which is accurate in many ways ... and of course .. may be innacurate too .. since I would argue that a family physician may provide better care in many ways than an internist or pediatrician - especially for a family.
But the point is that if these physicians could re-frame their identities as specialists in complex adult medicine - no longer would they be positioned as competition for family physicians, but as an available, supportive adjunct to comprehensive, coordinated care.
Last week, a patient transferred out of my practice. She had complex problems that I frankly told her I didn't understand. She asked for the name of another physician who might be helpful, and I suggested an Internist colleague who works across town. Bottom line: our Internist pal figured it out. Something rare and complicated and I hadn't even thought about it. But she did ... ordered the right tests, and I'm happy about that ... but now the relationship with my patient is severed .. and .. yes .. my ego is bruised a bit.
Had I referred the patient to a rheumatologist or cardiologist etc etc ... I wouldn't be severing the relationship with my patient -- nor would my ego be bruised by such a situation. Indeed, assistance with the diagnosis and/or management of a complex problem is the purpose of such a referral.
Hmm ... so, Dr. Bob (is that what DB stands for?) ... how would this work? Referrals to the Internist ... why not?