EDITORIALS
ANNALS of Internal Medicine Volume 9 0 • Number 6 June 1 9 7 9
P U B L I S H E D monthly by the American College of Physicians under the direction of the Publications Committee of the Board of Regents; see advertising page 1-5 for listing of the Committee, the Editorial Staff, the Editorial Board, and the Business Staff. Editorial Policy A N N A L S O F I N T E R N A L M E D I C I N E pub-
lishes original articles, case reports, topical reviews, editorials, book reviews, and medical news for internal medicine and related fields. Further details on the kinds of manuscripts that will be considered for possible publication are given in " I N F O R M A TION FOR A U T H O R S " on advertising page 1-6. Selected books will be critically reviewed or briefly described monthly. Review copies should be sent to the Assistant Editor. The content of A N N A L S OF I N T E R N A L
M E D I C I N E is protected by copyright. Manuscripts are accepted for publication with the understanding that their contents, all or in part, have not been published elsewhere and will not be published elsewhere, except in abstract form or by the express consent of the Editor. A N N A L S OF I N T E R -
N A L M E D I C I N E accepts no responsibility for statements made by contributors. Subscriptions A N N A L S O F I N T E R N A L M E D I C I N E is is-
sued monthly; new volumes begin with the January and July issues each year. Subscription price per year, net postpaid, A R E A I (North and Central America, Puerto Rico, Canal Zone): Students, $12.50; physicians out of medical school 4 years or less, $18.75; all others $25.00. A R E A II (all countries not in Area I): Students, $14.00; physicians out of medical school 4 years or less, $21.00; all others, $28.00. Single copies of recent issues: $3.00 in North and Central American countries, Puerto Rico, and Canal Zone; $3.25 in other countries; price of supplements provided on request. Checks should be made payable to the American College of Physicians and remitted to the Circulation Manager. Communications to the Editor or the Circulation Manager should be sent to
Annals of Internal Medicine 4 2 0 0 Pine St. Philadelphia, PA 1 9 1 0 4 USA Phone: 2 1 5 / 2 4 3 - 1 2 0 0
Yes, But What Do Internists Really Do? A L M O S T 15 YEARS AGO we reached a national consensus that equitable access to medical care was an appropriate social goal toward which to strive. Medicare and Medicaid were enacted to help the elderly and the poor, and these public programs dramatically increased the demand for outpatient services, particularly primary care. The national commitment to pay for these services led to a debate that centered upon three issues: Did we have adequate numbers of health care providers? Was the specialty mix of physicians appropriate to the needs of the country? Were health providers equitably distributed geographically? Between 1965 and 1970, three reports were published that led to the following conclusions: We were training too many specialists and not enough generalists (1); medical education should be modified to prepare more doctors to serve as "primary doctors" (2); and geographic distribution problems were related to an overall shortage of health providers that could be resolved by expanding enrollments in the nation's medical, dental, and nursing schools (3). These conclusions produced a flurry of public and private initiatives. With increasing federal support, medical school classes were expanded, many new medical schools were started, family practice training programs grew at explosive rates, new primary care residency tracks for internists and pediatricians were initiated, programs to train physician assistants were started, and nursing schools began to train some of their graduates for expanded roles in clinical practice. As a consequence, the medical care scene looks quite different today than it did a decade ago. We now have many more physicians, dentists, nurses, and other health professionals. Population groups that were previously the most poorly served, notably the poor and blacks seem to be getting a more equitable share of physicians' services, and statistics show the overall health of Americans is better (4). Despite these improvements, disagreements continue over the adequacy of physician manpower and the appropriateness of the "fit" between kinds of physicians trained and needs of the public for medical care. A recent Institute of Medicine study suggesting a continuing serious shortage in the number of physicians delivering primary care (5) was published almost simultaneously with Secretary Califano's conclusions that we are now producing too many doctors (6). This shows how disparate the views are. One of the principal reasons for such differences in opinion about where we stand is relatively straightforward: There has been a glaring lack of good information about what physicians actually do, who they care for in their practices, and the extent of the difficulties Americans have in obtaining medical care. As was recently noted by Thier and Berliner (7), opinions, not facts, have predominated in the continuing debate on primary care manpower. Within the last 5 years, there have been three major studies on the adequacy of the country's supply of health providers. 1. The Association of Professors of Medicine, in collaboration with the Federated Council of Internal Medicine, did a national study of
976
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19547/ by a University of California San Diego User on 01/30/2017
postgraduate education in internal medicine and its relation to projected manpower needs. The first two reports (8, 9) of that survey have been published in this journal, and others will be published over the next year. 2. A study of the problems Americans have in obtaining appropriate and responsive medical care was done at the University of Chicago by Andersen and his associates. Preliminary findings (10) give a more accurate view of the shortcomings in our access to medical care than was previously available. 3. A study of what physicians do in practice and of how their work relates to the fields in which they have been trained has been done at The University of Southern California by Mendenhall and his associates. The first in a series of papers from this study on internal medicine, "A National Study of the Specialties of Internal Medicine," appears in this issue (11). Additional papers that will be published in this journal over the next year will analyze issues of major interest to internists. Together, these three studies will, at long last, provide solid data upon which to base an assessment of current and future health manpower needs. The University of Southern California study, which was jointly sponsored by The Robert Wood Johnson Foundation and the Department of Health, Education, and Welfare, included a national sample of more than 10 000 physicians in 24 specialties, practicing in a variety of settings (12). The methods used were especially important: First, the data were obtained from log diaries of the almost minute-to-minute activities of physicians over assigned 3-day periods (13). This method was carefully monitored for reliability. Second, rather than asking physicians themselves to categorize their activities as "primary care," "specialty care," "consultative care," and so forth, the survey was designed to provide enough information on what physicians did, to allow an independent study group to characterize those activities. This permitted elimination of physicians' own perceptions of their activities, a problem that has marred most previous studies. The first paper in this series (11) explores what internists, who represent 16% of the practicing physician population, actually do in their practices. Internists work hard, although perhaps not quite as hard as some of their colleagues. They average 50 professional hours a week. They locate largely in metropolitan areas. The bulk of their practice time involves care of older persons who have multiple problems. That a large proportion of the problems they manage are acute and severe is suggested by the fact that more than 50% of their face-to-face patient encounters are in the hospital. More than one fourth of their patient contacts are via the telephone. The internist also engages in a significant number of non-patient-oriented pursuits. Significant amounts of time—20% to 40%—are allocated to teaching, to research, and to other professional activities. Perhaps of most interest to those involved in the intense debate about who does primary care is the fact that the study suggests that physicians who are labeled as "specialists" spend very significant amounts of their time in primary care activities (11). This finding is of enor-
mous potential importance to manpower planners. A paper by Aiken and her associates (14), based on the same data, substantiates and further documents this finding. It suggests that one of every five Americans now receives his or her "general" or "primary" or "principal" care from a physician who is labeled as, and regarded as, a "specialist." Thus there is now solid evidence that a "hidden system" of primary care exists in this country. Although this probability was noted some years ago (15, 16), it has not been previously documented or quantified. One may argue whether specialists should play this generalist role, but it is a vitally important fact of current American medicine. The "hidden system" has important implications for postgraduate medical education. Substantial numbers of specialists and subspecialists will need more generalist training if they are to provide primary care services to their regular patients. Tarlov and his associates (9) have documented that 25% of all first-year positions in internal medicine are occupied by physicians preparing for careers in fields other than internal medicine. This pressure on internal medicine to provide generalist training for other specialties is likely to continue. In addition to providing practice profiles, the series of manpower studies should provide a new perspective on differences in cost of care delivered by subspecialists as compared to generalists. Three factors dominate the cost debate: the differential fee structure that reimburses subspecialists at higher rates; the additional costs to the public of training subspecialists; and the greater use of hospitals by subspecialists. These three factors can be investigated using information from these three new studies. This will be an important series of papers. A s now planned, more than a dozen papers will appear in Annals of Internal Medicine in the months and perhaps years to come. They mark a unique cooperative effort among the specialty societies, the private sector, and the federal government to bring much needed information to bear on a central question of concern to all of us: how to plan for, train, and deploy health professionals to provide appropriate, effective, and continuing medical care to all Americans at costs we can afford. ( D A V I D E. ROGERS, M.D.; and L I N D A H. A I K E N , PH.D.; The Robert
Wood
Johnson
Foundation; Princeton, New Jersey) References 1. COGGESHALL LT: Planning for Medical Progress Through Education. Evanston, Illinois Association of American Medical Colleges, 1966 2. CITIZENS COMMISSION ON G R A D U A T E MEDICAL EDUCATION:
The
Graduate Education of Physicians; Report of the Commission. Chicago, American Medical Association, 1966 3. T H E CARNEGIE COMMISSION ON HIGHER EDUCATION: Higher Educa-
tion and the Nation s Health: Policies for Medical and Dental Education. New York, McGraw-Hill Book Company, 1970 4. ROGERS DE, BLENDON RJ: The changing American health scene. Sometimes things get better. JAMA 237:1710-1714, 1977 5. SCHEFFLER RM, WEISFELD N, R U B Y G, ESTES EH: A manpower poli-
cy for primary health care. N Engl J Med 298:1058-1062, 1978 6. BROAD WJ: Califano to medical schools: cut back class size. Science 202:726, 1978 7. THIER SO, BERLINER RW: Manpower policy: base it on facts, not opinions. N Engl J Med 299:1305-1307, 197S Editorials
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19547/ by a University of California San Diego User on 01/30/2017
977
8. T A R L O V AR, W E I L PA, S C H L E I T E R M K , T H E ASSOCIATION O F P R O FESSORS O F M E D I C I N E T A S K F O R C E ON M A N P O W E R : National Study of
Internal Medicine Manpower: I. Residency training 1976-1977. Ann Intern Med 88:413-420, 1978 9. W E I L PA, SCHLEITER MK, T A R L O V AR: National Study of Internal Medicine Manpower: II. A typology of residency training programs in internal medicine. Ann Intern Med 89 (Part 1):702-715, 1978 10. T H E R O B E R T W O O D J O H N S O N F O U N D A T I O N : Special Report
Number
One. Princeton, New Jersey, 1978 11. G I R A R D RA, M E N D E N H A L L RC, T A R L O V AR, R A D E C K I SE, A B R A -
HAMSON S: A national study of internal medicine and its specialties: I. An overview of the practice of internal medicine. Ann Intern Med 90:965-975, 1979 12.
13. M E N D E N H A L L RC, L L O Y D JS, R E P I C K Y PA, M O N S O N JR, G I R A R D
RA, ABRAHAMSON S: A national study of medical and surgical specialties. II. Description of the survey instrument. JAMA 240:1160-1168, 1978 14. A I K E N LH, L E W I S CE, C R A I G JE, M E N D E N H A L L RC, B L E N D O N RJ,
ROGERS DE: The contribution of specialists to the delivery of primary care: a new perspective. N Engl J Med, 1979, in press 15. M C D E R M O T T W: D O medical schools have to be restructured to produce the doctor of the future? Proceedings of Anglo-American Conference on Medical Care, Royal Society of Medicine, London, 5-7 April 1971, pp. 65-73 16. M C D E R M O T T W: General medical care: identification and analysis of alternative approaches. Johns Hopkins Med J 135:292-321, 1974
M E N D E N H A L L RC, G I R A R D RA, A B R A H A M S O N S: A national study of
medical and surgical specialties. I. Background, purpose, and methodology. JAMA 240:848-852, 1978
978
©1979 American College of Physicians
June 1979 • Annals of Internal Medicine • Volume 90 • Number 6
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19547/ by a University of California San Diego User on 01/30/2017
ANNALS of Internal Medicine Volume 9 0 • Number 6 June 1 9 7 9
P U B L I S H E D monthly by the American College of Physicians under the direction of the Publications Committee of the Board of Regents; see advertising page 1-5 for listing of the Committee, the Editorial Staff, the Editorial Board, and the Business Staff. Editorial Policy A N N A L S O F I N T E R N A L M E D I C I N E pub-
lishes original articles, case reports, topical reviews, editorials, book reviews, and medical news for internal medicine and related fields. Further details on the kinds of manuscripts that will be considered for possible publication are given in " I N F O R M A TION FOR A U T H O R S " on advertising page 1-6. Selected books will be critically reviewed or briefly described monthly. Review copies should be sent to the Assistant Editor. The content of A N N A L S OF I N T E R N A L
M E D I C I N E is protected by copyright. Manuscripts are accepted for publication with the understanding that their contents, all or in part, have not been published elsewhere and will not be published elsewhere, except in abstract form or by the express consent of the Editor. A N N A L S OF I N T E R -
N A L M E D I C I N E accepts no responsibility for statements made by contributors. Subscriptions A N N A L S O F I N T E R N A L M E D I C I N E is is-
sued monthly; new volumes begin with the January and July issues each year. Subscription price per year, net postpaid, A R E A I (North and Central America, Puerto Rico, Canal Zone): Students, $12.50; physicians out of medical school 4 years or less, $18.75; all others $25.00. A R E A II (all countries not in Area I): Students, $14.00; physicians out of medical school 4 years or less, $21.00; all others, $28.00. Single copies of recent issues: $3.00 in North and Central American countries, Puerto Rico, and Canal Zone; $3.25 in other countries; price of supplements provided on request. Checks should be made payable to the American College of Physicians and remitted to the Circulation Manager. Communications to the Editor or the Circulation Manager should be sent to
Annals of Internal Medicine 4 2 0 0 Pine St. Philadelphia, PA 1 9 1 0 4 USA Phone: 2 1 5 / 2 4 3 - 1 2 0 0
Yes, But What Do Internists Really Do? A L M O S T 15 YEARS AGO we reached a national consensus that equitable access to medical care was an appropriate social goal toward which to strive. Medicare and Medicaid were enacted to help the elderly and the poor, and these public programs dramatically increased the demand for outpatient services, particularly primary care. The national commitment to pay for these services led to a debate that centered upon three issues: Did we have adequate numbers of health care providers? Was the specialty mix of physicians appropriate to the needs of the country? Were health providers equitably distributed geographically? Between 1965 and 1970, three reports were published that led to the following conclusions: We were training too many specialists and not enough generalists (1); medical education should be modified to prepare more doctors to serve as "primary doctors" (2); and geographic distribution problems were related to an overall shortage of health providers that could be resolved by expanding enrollments in the nation's medical, dental, and nursing schools (3). These conclusions produced a flurry of public and private initiatives. With increasing federal support, medical school classes were expanded, many new medical schools were started, family practice training programs grew at explosive rates, new primary care residency tracks for internists and pediatricians were initiated, programs to train physician assistants were started, and nursing schools began to train some of their graduates for expanded roles in clinical practice. As a consequence, the medical care scene looks quite different today than it did a decade ago. We now have many more physicians, dentists, nurses, and other health professionals. Population groups that were previously the most poorly served, notably the poor and blacks seem to be getting a more equitable share of physicians' services, and statistics show the overall health of Americans is better (4). Despite these improvements, disagreements continue over the adequacy of physician manpower and the appropriateness of the "fit" between kinds of physicians trained and needs of the public for medical care. A recent Institute of Medicine study suggesting a continuing serious shortage in the number of physicians delivering primary care (5) was published almost simultaneously with Secretary Califano's conclusions that we are now producing too many doctors (6). This shows how disparate the views are. One of the principal reasons for such differences in opinion about where we stand is relatively straightforward: There has been a glaring lack of good information about what physicians actually do, who they care for in their practices, and the extent of the difficulties Americans have in obtaining medical care. As was recently noted by Thier and Berliner (7), opinions, not facts, have predominated in the continuing debate on primary care manpower. Within the last 5 years, there have been three major studies on the adequacy of the country's supply of health providers. 1. The Association of Professors of Medicine, in collaboration with the Federated Council of Internal Medicine, did a national study of
976
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19547/ by a University of California San Diego User on 01/30/2017
postgraduate education in internal medicine and its relation to projected manpower needs. The first two reports (8, 9) of that survey have been published in this journal, and others will be published over the next year. 2. A study of the problems Americans have in obtaining appropriate and responsive medical care was done at the University of Chicago by Andersen and his associates. Preliminary findings (10) give a more accurate view of the shortcomings in our access to medical care than was previously available. 3. A study of what physicians do in practice and of how their work relates to the fields in which they have been trained has been done at The University of Southern California by Mendenhall and his associates. The first in a series of papers from this study on internal medicine, "A National Study of the Specialties of Internal Medicine," appears in this issue (11). Additional papers that will be published in this journal over the next year will analyze issues of major interest to internists. Together, these three studies will, at long last, provide solid data upon which to base an assessment of current and future health manpower needs. The University of Southern California study, which was jointly sponsored by The Robert Wood Johnson Foundation and the Department of Health, Education, and Welfare, included a national sample of more than 10 000 physicians in 24 specialties, practicing in a variety of settings (12). The methods used were especially important: First, the data were obtained from log diaries of the almost minute-to-minute activities of physicians over assigned 3-day periods (13). This method was carefully monitored for reliability. Second, rather than asking physicians themselves to categorize their activities as "primary care," "specialty care," "consultative care," and so forth, the survey was designed to provide enough information on what physicians did, to allow an independent study group to characterize those activities. This permitted elimination of physicians' own perceptions of their activities, a problem that has marred most previous studies. The first paper in this series (11) explores what internists, who represent 16% of the practicing physician population, actually do in their practices. Internists work hard, although perhaps not quite as hard as some of their colleagues. They average 50 professional hours a week. They locate largely in metropolitan areas. The bulk of their practice time involves care of older persons who have multiple problems. That a large proportion of the problems they manage are acute and severe is suggested by the fact that more than 50% of their face-to-face patient encounters are in the hospital. More than one fourth of their patient contacts are via the telephone. The internist also engages in a significant number of non-patient-oriented pursuits. Significant amounts of time—20% to 40%—are allocated to teaching, to research, and to other professional activities. Perhaps of most interest to those involved in the intense debate about who does primary care is the fact that the study suggests that physicians who are labeled as "specialists" spend very significant amounts of their time in primary care activities (11). This finding is of enor-
mous potential importance to manpower planners. A paper by Aiken and her associates (14), based on the same data, substantiates and further documents this finding. It suggests that one of every five Americans now receives his or her "general" or "primary" or "principal" care from a physician who is labeled as, and regarded as, a "specialist." Thus there is now solid evidence that a "hidden system" of primary care exists in this country. Although this probability was noted some years ago (15, 16), it has not been previously documented or quantified. One may argue whether specialists should play this generalist role, but it is a vitally important fact of current American medicine. The "hidden system" has important implications for postgraduate medical education. Substantial numbers of specialists and subspecialists will need more generalist training if they are to provide primary care services to their regular patients. Tarlov and his associates (9) have documented that 25% of all first-year positions in internal medicine are occupied by physicians preparing for careers in fields other than internal medicine. This pressure on internal medicine to provide generalist training for other specialties is likely to continue. In addition to providing practice profiles, the series of manpower studies should provide a new perspective on differences in cost of care delivered by subspecialists as compared to generalists. Three factors dominate the cost debate: the differential fee structure that reimburses subspecialists at higher rates; the additional costs to the public of training subspecialists; and the greater use of hospitals by subspecialists. These three factors can be investigated using information from these three new studies. This will be an important series of papers. A s now planned, more than a dozen papers will appear in Annals of Internal Medicine in the months and perhaps years to come. They mark a unique cooperative effort among the specialty societies, the private sector, and the federal government to bring much needed information to bear on a central question of concern to all of us: how to plan for, train, and deploy health professionals to provide appropriate, effective, and continuing medical care to all Americans at costs we can afford. ( D A V I D E. ROGERS, M.D.; and L I N D A H. A I K E N , PH.D.; The Robert
Wood
Johnson
Foundation; Princeton, New Jersey) References 1. COGGESHALL LT: Planning for Medical Progress Through Education. Evanston, Illinois Association of American Medical Colleges, 1966 2. CITIZENS COMMISSION ON G R A D U A T E MEDICAL EDUCATION:
The
Graduate Education of Physicians; Report of the Commission. Chicago, American Medical Association, 1966 3. T H E CARNEGIE COMMISSION ON HIGHER EDUCATION: Higher Educa-
tion and the Nation s Health: Policies for Medical and Dental Education. New York, McGraw-Hill Book Company, 1970 4. ROGERS DE, BLENDON RJ: The changing American health scene. Sometimes things get better. JAMA 237:1710-1714, 1977 5. SCHEFFLER RM, WEISFELD N, R U B Y G, ESTES EH: A manpower poli-
cy for primary health care. N Engl J Med 298:1058-1062, 1978 6. BROAD WJ: Califano to medical schools: cut back class size. Science 202:726, 1978 7. THIER SO, BERLINER RW: Manpower policy: base it on facts, not opinions. N Engl J Med 299:1305-1307, 197S Editorials
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19547/ by a University of California San Diego User on 01/30/2017
977
8. T A R L O V AR, W E I L PA, S C H L E I T E R M K , T H E ASSOCIATION O F P R O FESSORS O F M E D I C I N E T A S K F O R C E ON M A N P O W E R : National Study of
Internal Medicine Manpower: I. Residency training 1976-1977. Ann Intern Med 88:413-420, 1978 9. W E I L PA, SCHLEITER MK, T A R L O V AR: National Study of Internal Medicine Manpower: II. A typology of residency training programs in internal medicine. Ann Intern Med 89 (Part 1):702-715, 1978 10. T H E R O B E R T W O O D J O H N S O N F O U N D A T I O N : Special Report
Number
One. Princeton, New Jersey, 1978 11. G I R A R D RA, M E N D E N H A L L RC, T A R L O V AR, R A D E C K I SE, A B R A -
HAMSON S: A national study of internal medicine and its specialties: I. An overview of the practice of internal medicine. Ann Intern Med 90:965-975, 1979 12.
13. M E N D E N H A L L RC, L L O Y D JS, R E P I C K Y PA, M O N S O N JR, G I R A R D
RA, ABRAHAMSON S: A national study of medical and surgical specialties. II. Description of the survey instrument. JAMA 240:1160-1168, 1978 14. A I K E N LH, L E W I S CE, C R A I G JE, M E N D E N H A L L RC, B L E N D O N RJ,
ROGERS DE: The contribution of specialists to the delivery of primary care: a new perspective. N Engl J Med, 1979, in press 15. M C D E R M O T T W: D O medical schools have to be restructured to produce the doctor of the future? Proceedings of Anglo-American Conference on Medical Care, Royal Society of Medicine, London, 5-7 April 1971, pp. 65-73 16. M C D E R M O T T W: General medical care: identification and analysis of alternative approaches. Johns Hopkins Med J 135:292-321, 1974
M E N D E N H A L L RC, G I R A R D RA, A B R A H A M S O N S: A national study of
medical and surgical specialties. I. Background, purpose, and methodology. JAMA 240:848-852, 1978
978
©1979 American College of Physicians
June 1979 • Annals of Internal Medicine • Volume 90 • Number 6
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19547/ by a University of California San Diego User on 01/30/2017
