General internal medicine: smaller and smaller?

The American Board of Internal Medicine, for a variety of reasons, has embarked on the institution of a series of "maintenance of certification" examinations to evaluate internists. In addition to mandatory periodic recertification in their general core competencies, internists can now take an additional examination in a component of the specialty in which they predominantly work. This tailoring of supplemental "special" modules to the actual daily practice and interests of the examinees clearly has great appeal; it is also, I believe, fraught with hazards for both general internists and their patients, as well as for many already well-established internal medicine subspecialists.

The ABIM most recently has developed, for presentation to the American Board of Medical Specialties, a new cardiology subspecialty in "advanced heart failure and transplantation cardiology," which will affect the scope of practice and perceived expertise of both general internists and cardiologists. Although cardiac transplantation is certainly cardiology territory, heart failure--even severe heart failure--is currently often managed primarily by general internists with consultation from cardiologists.

Paradoxically, the ABIM is also designing an elective recertification module for what it calls "comprehensive internal medicine," which is aimed at the broad-based general internist. That is precisely the sort of physician the public says it wants: an empathetic expert clinician who knows and cares for them. He or she should have, by virtue of cross-subspecialty knowledge and skills, the integrative expertise and personal knowledge of individual patients over time (in both inpatient and outpatient settings) that is needed to guide patients who often have multiple, complex, or simultaneous problems. This requires using judgment, communication, and an informed vision of the whole in order to balance that patient's concerns and needs with system constraints.

It is disingenuous of the ABIM, I think, to feign support for the so-called "comprehensive internist" while simultaneously depleting the general internist's portfolio of certified legitimacy in some of the more highly valued components of recognized expertise, such as management of heart failure and of hospitalized patients. This threatens to further shift the work of general internists to a support function not only for the classic subspecialists of medicine but also for the "certified modular" subspecialists. It potentially leaves the so-called comprehensive internist, already beset and underappreciated by payers and systems, to do predominantly triage, health information technology, social services, counseling, prevention, screening, and general organizational and secretarial functions for the "experts." I doubt that many young internists in training will aspire to this role, especially because its many components can be done better and more efficiently by nonphysician personnel.

And no matter what the ABIM hopes to design for the general internist, it is clear that systems, payers, hospitals, lawyers, and physicians themselves will perceive the "modular certification holders" or "new generation subspecialties" as having received the imprimatur of the ABIM for their special expertise, which will give them added legitimacy and increased (remunerative) value. It also undeniably implies that those who remain broad-based general internists do not have this special expertise.

Moreover, the role of classic internal medicine subspecialists is unaddressed: Will they now also be deprived of opportunities for consultation and care of a number of patients formerly within their subspecialty? I will be interested to find out which patients--in the view of broad-based cardiologists--will fall within (and, more pertinently, without) the proposed new subsubspecialty in severe heart failure.

As a general internist who has for decades treated both outpatients and inpatients (more than enough to qualify me as a "hospitalist" if I chose to be so titled), I am deeply disturbed by the culture and systems that scatter and fragment care, frustrating both my patients and me by giving me the responsibility for my patients but not the resources or the perceived authority to act in what I believe is their best interest. The general internist now seems rather like Alice in Wonderland, as she felt the effects of the magic drink that shrank her down to smaller size--"for it might end, you know," said Alice to herself, "in my going out altogether, like a candle. I wonder what I should be like then?"

The ABIM could still offer additional voluntary examinations in selected areas of practice, but without designating those who choose to do them as anything other than general internists recertified in general internal medicine, thereby not implying that other general internists are excluded from those areas.

If the ABIM continues on its present course, it will, I think, give the last of the lacerations to the current ongoing death by a thousand cuts of the general internist. Does this really, as ABIM maintains, "add value" and improve our patients' and our nation's health?

DR. FITZGERALD is professor of medicine and associate dean of the humanities and bioethics program at the University of California, Davis.

BY FAITH T. FITZGERALD, M.D.