Internal Subspecialties Research Articles

Internists' Response to Primary Care Medicaid Pay Is Positive Yet Cautious

Internists' Response to Primary Care Medicaid Pay Is Positive Yet Cautious

Smoking habits and teachable moment among hospitalized patients admitted to the internal medicine department

Hospitalization seems a favorable setting to quit smoking. The purpose of this study was to determine the smoking habits and teachable moments among hospitalized patients admitted to the internal medicine department. A prospective study involving 253 patients admitted to an academic teaching hospital was conducted. The rate of current smokers ranged from 75% in the group of 30 to 39-year-old male patients to 0% in female patients 80 years and older; mean prevalence 34%. Although males had a higher prevalence of smoking in the younger population, the number of current smokers between the genders nearly converged in patients greater or equal to 50 years of age. Among the internal subspecialties, it was highest in patients admitted for pulmonary disease. The number of patients that quit smoking before discharge was similar between both genders, but significantly different among the age-groups and subspecialties. The fraction of quitters was greater in patients 50 years and older, compared to patients less than 50 years (35% vs. 11%, respectively), and in patients admitted for pulmonary disease, compared to all other patients (33% vs. 12%, respectively). In summary, smoking habits among inpatients are very heterogenous, depending on age, gender, and medical reason for admission. Highest prevalences are found in young, male patients, as well as patients admitted for pulmonary disease. On the other hand, the rate of quitters is significantly greater in patients 50 years and older, and patients admitted for pulmonary disease. Besides targeting our efforts at those who are susceptible to the effects, within the scope of secondary and tertiary prevention of many chronic pulmonary and cardiac diseases, it might be favorable and most efficient to focus on the young, middle-aged patients in tailoring specific support, especially in respiratory medicine.

Smoking habits and teachable moment among hospitalized patients admitted to the internal medicine department

Hospitalization seems a favorable setting to quit smoking. The purpose of this study was to determine the smoking habits and teachable moments among hospitalized patients admitted to the internal medicine department. A prospective study involving 253 patients admitted to an academic teaching hospital was conducted. The rate of current smokers ranged from 75% in the group of 30 to 39-year-old male patients to 0% in female patients 80 years and older; mean prevalence 34%. Although males had a higher prevalence of smoking in the younger population, the number of current smokers between the genders nearly converged in patients greater or equal to 50 years of age. Among the internal subspecialties, it was highest in patients admitted for pulmonary disease. The number of patients that quit smoking before discharge was similar between both genders, but significantly different among the age-groups and subspecialties. The fraction of quitters was greater in patients 50 years and older, compared to patients less than 50 years (35% <em>vs.</em> 11%, respectively), and in patients admitted for pulmonary disease, compared to all other patients (33% <em>vs.</em> 12%, respectively). In summary, smoking habits among inpatients are very heterogenous, depending on age, gender, and medical reason for admission. Highest prevalences are found in young, male patients, as well as patients admitted for pulmonary disease. On the other hand, the rate of quitters is significantly greater in patients 50 years and older, and patients admitted for pulmonary disease. Besides targeting our efforts at those who are susceptible to the effects, within the scope of secondary and tertiary prevention of many chronic pulmonary and cardiac diseases, it might be favorable and most efficient to focus on the young, middle-aged patients in tailoring specific support, especially in respiratory medicine.

Educational needs of internal medicine residency graduates: general internist versus subspecialists

Residency training is inadequate with respect to the needs of general internal medicine doctors in several areas. We undertook this study to determine the practice habits and educational requirements of general versus subspecialty internists. A survey was mailed to 138 doctors who had completed at least a three-year university-based internal medicine post-graduate training. Sixty-three (46%) responded, of whom 32 completed additional training in a subspecialty of internal medicine. Many (14 of 32) subspecialists described their practice as general internal medicine (GIM) with a subspecialty emphasis. GIM was as important to their practice as it was to the general internists. General internists saw non-internal medicine disciplines as important but subspecialists did not. General internists frequently performed procedures that were not formally taught during training, while subspecialists rarely if ever performed a procedure outside the scope of their fellowship training. Internal medicine training programmes should be able to individualize training based on the career choices of trainees such that training will more fully prepare trainees for practice.

Change in self-definition from specialist to generalist in a national sample of physicians.

Current proposals to reform the health care system call for a physician work force composed of at least 50% generalists. Achieving this objective will likely require that some physicians who are currently specialists become generalists. We sought to determine the extent of such change before any concerted reform efforts and the types of physicians most amenable to such change. Retrospective cohort study. 335,438 physicians in active practice. Rates of change between 1982 and 1986 in self-defined specialties, analyzed with demographic methods and logistic regression. In 1982, our participants comprised 134,647 (40.1%) generalists and 200,791 (59.9%) specialists. Over the 4-year period of the study, 8319 (6.2%) of the generalists became specialists and 4322 (2.2%) of the specialists became generalists. Although physicians younger than 40 years of age were more likely than those older than 40 years of age to switch into generalist disciplines, specialist physicians between the ages of 40 and 69 years (who accounted for 62.0% of the physician work force) made most of the moves into generalist fields (58.4%). After adjustment for other factors, the physicians most likely to switch into generalist disciplines were women, subspecialty internists, emergency medicine physicians, subspecialty pediatricians, and pathologists. In 1986, the 130,650 physicians (38.9%) in this cohort who considered themselves generalists were supplemented by another 49,226 (14.7%) who considered themselves to have a secondary interest in generalist practice. Physicians with such a secondary interest in 1982 constituted 65% of the new generalists in 1986. Our findings support three principal conclusions. First, change from specialist to generalist disciplines is not uncommon, even for physicians older than 40 years of age. Second, many physicians already consider a generalist discipline to be a secondary emphasis of their practices. And third, efforts to retrain specialists to be generalists might effectively target those physicians predisposed to become generalists.

After-hours telephone calls to general and subspecialty internists

To study the after-hours telephone calls received by practicing general and subspecialty internists. Observational study. Forty-four internal medicine private practices in Long Island, New York, consisting of 70 physicians (31 general internists, 39 internists with subspecialty training). All calls received by an answering service after office hours with the caller requesting to speak to one of the physicians in the study. Of the 8,444 total calls, 2,950 were to generalists and 5,494 were to subspecialists. For both groups, most calls came from patients (46.3%), followed by physicians (26.0%), then hospitals (22.2%). For patient calls to the generalists, those concerning infectious disease (15.4%), nonspecific symptoms (11.1%), medication-related questions (9.7%), and gastrointestinal (GI) complaints (9.4%) were the most common. For those calls to the specialists, GI (14.2%), infectious disease (10.9%), medication-related (10.0%), and nonspecific symptom (9.0%) complaints represented the most common patient calls. Although GI and cardiology specialists received proportionally more patient calls related to their specialities, the specialty group, like the generalist group, received calls in all the major areas of internal medicine. Patient calls for problems well outside the traditional scope of internal medicine accounted for 2.9% of the calls to the generalists and 1.9% of the calls to the specialists. About 44% of the patient calls to both groups were for potentially serious problems. After 11:00 PM both groups saw a decrease in the proportions of minor and trivial calls. These observations support the concept of broadly based medical training for both internal medicine generalists and subspecialist in preparation for the variety of telephone calls they will deal with after office hours. Practitioners should take steps to reduce the high number of medication-related patient calls.

General internal medicine practice trends in large multispecialty clinics

To assess practice trends in the general internal medicine departments of large multispecialty clinics. A survey questionnaire addressing the following issues: 1) department size and rate of growth, 2) services provided, 3) patient population, 4) individual clinical workload, 5) call arrangements, 6) time away from practice, and 7) benefits and salary. 22 multispecialty clinics, with a mean of 279 physicians. Mean general internal medicine department physician expansion was 28% over the preceding three years. Primary care, clinic system access, care of patients laterally shifted from subspecialty internists, and preoperative evaluations were the four major services provided. The mix of fee-for-service, Medicare/Medicaid, and prepaid-plan patients was diverse. Mean outpatient clinical scheduling was 35 hours per week exclusive of hospital practice, administrative time, and paperwork. Study of call arrangements revealed a definite trend toward a group practice model of shared responsibility during the day as well as nights and weekends. Mean meeting and vacation time was 35 days per year. Salary was set by committee, formula, or both. Department stresses and dissatisfactions were also reported. Rapid expansion of general internal medicine departments and services will continue as subspecialists back away from providing primary care. The evolution of general internal medicine practice must be anticipated and managed for optimal patient and departmental outcomes.

Training in a Primary Care Internal Medicine Residency Program

We surveyed all 49 graduates of the University of California, San Francisco, residency program in primary care internal medicine to determine whether they chose careers as general internists and whether training in ambulatory care at the expense of hospital-based medicine is adequate preparation for general internal medicine practice. Graduates rated adequacy of training and relevance to their current clinical practice of 87 content and skill areas on five-point Likert scales. Of the 44 respondents, 39 (89%) chose careers as general internists and five (11%) as subspecialty internists. Training in nine of 11 internal medicine disciplines (eg, cardiology) was rated as highly adequate, and the areas as highly relevant. For ten of 15 non-internal medicine areas (eg, ear, nose, and throat), mean relevance scores significantly exceeded adequacy scores, suggesting training underemphasis. Mean relevance scores also significantly exceeded adequacy scores for seven of 11 basic knowledge/skill areas (eg, patient interviewing) and 13 of 14 areas related to clinical practice (eg, quality assurance). We conclude that the vast majority of graduates of the University of California, San Francisco, primary care residency program became general internists and that, rather than feeling deficient in training in hospital-based medicine, graduates reported unmet needs for ambulatory-care experiences and skills related to general internal medicine practice.

Changes in the supply of internists: the internal medicine population from 1978 to 1998.

Between 1978 and 1985, the number of active internists in the United States increased from 64,000 to 91,000, and by 1998 the number will have increased to 141,000. This growth represents an increase of 121% for a 20-year period, during which time the population of the United States is expected to increase only 19%. Thus, the number of adults older than 17 years per active internist will drop from 2464 to 1401. Between 1978 and 1998, we expect the number of subspecialty internists to increase 206%, in contrast to a 77% increase expected for general internists. The proportion of female internists will increase from 7% to 21%. The proportion of the active internist population who are foreign medical graduates will remain stable at about 21% throughout the projection period, but within this group the proportion who are United States citizens is expected to increase while the proportion who are foreign citizens is expected to decline.

Training Internists in Ambulatory Settings

Residency training in internal medicine must adjust to two new realities: the change in the nature of hospitalized patients, and the growing oversupply of internal medicine subspecialists. Technology and economies have changed the substrate of hospital practice dramatically. Consequently, hospital training has increasingly focused on chronically disabled patients, those admitted for elective procedures, or those who are terminally ill.¹Thus, residents have less exposure to acute illnesses and to acute diagnostic and management decisions. Despite a growing oversupply of internal medicine subspecialists,²at least 60% of internal medicine residency graduates go on to subspecialty training. Schleiter and Tarlov estimate that by the year 2000 more than 50% of all internists will be subspecialists.³It is unlikely, however, that the typical internal medicine subspecialist can sustain a subspecialty practice exclusively; many subspecialty internists will also have to function as part-time generalists.⁴ Primary care internal medicine has emerged

Generalists and Specialists-Reply

In Reply.— As a family physician and family practice educator, I have no quarrel with Dr McMillen's assessment of medical care in the real world and, in fact, share his enjoyment of office and community hospital medical practice. Both he and Dr Davidson 1 have taken my letter as a criticism of the competence and viability of the primary care internist when it was intended as a commentary on the traditional academic perspective. Although I trained in family practice, a good deal of my time was spent in contact with internal medicine residents, practitioners, and faculty. In this academic setting, residents aspired to the knowledge, skills, and roles of their faculty mentors—academic subspecialty internists who themselves pursued the goal of becoming Dr Petersdorf's 2 triple threat academicians. Although often acknowledged as good physicians and sometimes as astute clinicians, practitioners of general internal medicine were not the role models for these residents.

Generalists and Specialists

To the Editor.— The failure of internal medicine residency programs to produce substantial numbers of generalist v subspecialty internists has been the subject of much discussion, including the recent commentary inThe Journalby Dr Davidson. A factor that seems to me a major one in dissuading residents from the generalists track is that in such a career they would, from a resident's perspective, face a lifetime of diminishing competence. To illustrate that, I ask you to consider this question: If you were acutely ill with diabetic ketoacidosis, pneumonia, and a complicated myocardial infarction, were admitted to a University Medical Center, and could choose only one physician to provide your care, who would it be? For me the answer is simple. I would choose the chief medical resident. I would do so because in the world of the complex acutely ill patients of the teaching hospital medical wards, he or

Textbook of General Medicine

Encountering the title of this book for the first time, one might be led to exclaim: What, another textbook covering all of medicine! Already available are more comprehensive volumes such asThe Scientific American's compendium updated monthly by computer, through the classic texts of Cecil and Harrison, to concise practical treatises like theMerck Manualor the paperbackManual of Medical Therapeuticsby the Washington University faculty, St Louis. Where, then, does the present volume belong among the proliferating choices of texts providing the essentials of internal medicine? This soft-cover volume consists of 15 chapters written by 22 subspecialty internists, ten of whom are faculty members at the Medical College of Wisconsin, Milwaukee. The primary audience is clearly the medical student who wishes to read a general overview of internal medicine either straight through or chapter by chapter, as it relates to his or her clinical experience during a

National study of Internal Medicine Manpower: VIII. Internal medicine residency and fellowship training: 1983 update.

A national census of internal medicine residency and fellowship training programs was done in 1981 and 1982, a continuation of surveys conducted annually since 1976. The number of residents in training continues to rise in relation to the increasing number of U.S. medical school graduates. U.S. citizens who are graduates of foreign medical schools comprise a rising number of the residents, 11.6% of the first-year trainees in 1982-1983. Foreign-born graduates of foreign medical schools have declined in the last 2 years to 9.9% of all first-year trainees. The number of blacks in residency training remains less than 5% of the trainee population. More than half of the residents entered subspecialty fellowship training after the completion of residency training. This finding predicts a continuing increase in the ratio of subspecialty internists to general internists in the practicing internal medicine population. The implications of these results for public policy are discussed.