SPECIAL ARTICLE

Training Internists: Insights from Private Practice

JACK D. McCUE, M.D.*

Greensbom. North Carolina

University internal medicine training programs concentrate on the traditional curriculum designed to produce well-trained academi- cians and researchers. Increasingly internists are involved in primary patient care with over two-thirds being office based practitioners. Residency training at these institutions must make available to all residents the opportunity to learn the skills taught by primary care programs. Clinical problem solving, skills in patient-physician ne- gotiations and patient comfort, psychiatric techniques, medical ethics, cost effectiveness analysis, and practice management are areas in which the private practitioner frequently needs help. Feedback from training program graduates in private practice could help identify such deficiencies which could be incorporated Into the teaching responsibility of a division of general internal medicine.

Accepting a faculty position in a university-based training program after five years of solo private practice produced some surprises. I discovered that my new colleagues did not share my respect for the strengths of practicing internists, but, even worse, university training programs made few efforts to identify the educational needs of the practicing internist and to correct deficiencies. In fact, program di- rectors seemed to be consciously training residents to emulate their faculty, educating them to be subspecialists and academicians.

Over 90 percent of the graduates of internal medicine programs are involved in patient care, and over two thirds of those are office- based practitioners [ 11. A majority of all practicing internists’ time, except for allergists and infectious disease specialists, is employed in first encounter and principal care of patients; only 5 to 10 percent of their time is spent providing specialized care to patients who have other principal care physicians [ 21. Interestingly, the proportions of time spent in principal, first encounter and specialized care is about the same for general internists and subspecialists, and the economics of private practice will insure that specialists continue to spend some, if not most, of their time providing principal and first encounter care.

From the University of North Carolina, Chapel Hill, North Carolina. Requests for reprints should be addressed to Dr. Jack D. McCue, Medical Teach- ing Service, Moses H. Cone Memorial Hospital, Greensboro, NC 27420. Manuscript accepted April 27, 1!381.

Primary care programs are a response to the perception that in- ternists must be able to provide first encounter and principal care. They have established in the clinic, a weak power base indeed in academia, a faculty concerned with the training of practicing internists. Unfor- tunately, by concentrating on residents who have committed them- selves to a primary care track as fourth year students, the faculty has little influence on the great majority of residents, who are being trained as “organ” doctors, Furthermore, it is doubtful that devoting up to half of a resident’s training to outpatient medicine [3] is an efficient or effective way to teach the primary care curriculum.

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General internal medicine divisions are a better re- sponse to the recognition that very important parts of an internist’s education simply do not fit into the teaching responsibilities of any of the subspecialty di- visions. Department chairmen and subspecialty faculty have trouble understanding just which academic pi- geonhole general internists fit into and what, besides running the clinic, they are supposed to do. Other, likely related, problems faced by general internal medicine faculty include difficulty in gaining recognition and promotion by the university [ 41.

faculty members will recognize in the following list the areas in which their residents do poorly. It is not sur- prising that practicing internists also do poorly-it is very difficult for a physician to learn a body of knowl- edge when the foundations have not been laid in med- ical school or residency.

What have we taught well?

Thousands of capable internists are trained yearly, re- sponsible in a large part for the world-recognized ex- cellence of American medicine. Medical schools and university training programs have, in short, done well most of what they have tried to do.

(1) Depth of knowledge in subspecialties: The peer pressure for making a diagnostic “coup” and for not missing an unusual presentation of a rare illness is strong and persistent-internists are still often called diagnosticians. The penchant of the internist for pre- cision in thinking and his pleasure in sleuthing are, I suspect, what attracts students to internal medicine. It is gratifying how rarely general internists or subspeci- alists need consultations from other subspecialists for patient management problems except for diagnostic procedures.

(1) Clinical problem solving: Acquisition of facts dominates premedical, medical and postgraduate ed- ucation. Eichna [5] spent four years in his medical school as a “born-again” student learning, among other things, that “fact is king.” It is easy to teach facts, hence the popular lecture format, and to test for their acqui- sition with multiple choice questions. It is difficult and time-consuming to teach clinical problem solving, and few academicians teach it well. Blois [ 81 notes that eliciting positive clinical information, determining the relevance of that information and narrowing the diag- nostic possibilities are areas in which the physician outperforms the computer, which excells at applying rules to facts. Good clinicians intuitively use common sense and medical experience to determine relevance, but many just apply rules to facts, what is usually taught in residency programs. Patients come to their internists for problem-solving and judgment, not rules and facts.

What is the problem?

(2) Data gathering: Despite what must seem to some as determined efforts to tear the student from the bedside, and our patchy and disorganized efforts at teaching physical diagnosis [ 51, practicing internists somehow have learned to obtain a complete history and physical. Physical findings are rarely missed: the history is usually compulsively recorded, and most internists have a general understanding of their patient’s psy- chosocial background, even though they may neglect to record it.

Our “organ doctor” training teaches us to look for a disease or diagnosis, often missing the reason for the patient’s visit. For example, a patient with a headache has a diagnosis of tension headache, but the “problem” is unhappiness or depression. An 80 year old woman has a systolic blood pressure of 185 mm Hg. The di- agnosis is familial systolic hypertension but the real problem is to preserve the quality of her life. If by low- ering the systolic pressure we increase the possibility of a few extra months of life, but give her nightmares and depression with propranolol, we have ignored the real problem.

(3) Motivation for continuing education: Most in- The recognition of “the problem” rather than the

ternists allot up to 5 percent of their net income and two disease was taught by experienced teacher clinicians

weeks of their time to postgraduate education, in ad- [9] who are now largely gone from the halls of acade-

dition to their hospital educational activities. Lack of mia. We must make efforts to expose residents to

attention to the purposes and techniques of postgrad- clinicians who can reduce complex medical cases to

uate teaching are, I believe, the problem, not lack of problems and goals, and humanize biomedical tech-

motivation [6] which appears to be the focus of legis- nology.

lation regulating medical re-licensure. Perhaps the fu- ture focus of postgraduate programs should be imple- mentation of knowledge, to diminish the discrepancy between what a physician knows and what he does

171.

Where are the decision nodes?

Buried in the tangle of the complicated decision trees of clinical decision analysis [lo] are important lessons which every resident must learn. The first question a

What must we teach better? resident asked on encountering a hypertensive patient a decade ago was “Has a hypertension work-up been done?.” The decision node for a work-up has now shifted far along the hypertension decision tree, and we

The voids in an internist’s education are largely in areas university programs do not try to teach. Most university

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now ask “‘Is a hypertension work-up needed for this patient?” after determining age, sex, race, family his- tory, suspicious symptoms and ease of control with drugs. Decisions must be made in the proper sequence, determined by knowledge of the disease, cost-effec- tiveness and the individual needs of the patient. Every resident should be exposed to the intellectual rigors of writing a decision tree or a protocol for a common ill- ness. For example, a decision tree for the evaluation of sore throat in an adult, considering the current rarity of acute rheumatic fever, would yield intellectually stimulating results.

What are the odds?

Physicians rarely deal with certainty-every patient encounter involves a multitude of gambles. Our lack of attention to the process of playing the odds has per- mitted unnecessary sloppiness in problem-solving and clinical thinking. If residents were asked to assign a probability to all their “clinical hunches,” the impact on self education and cost containment would be enor- mous. For example, if the odds of a cell-wall antibi- otic-resistant gram-negative bacillary pneumonia were estimated to be 1 of 100, adding an aminoglycoside antibiotic would probably actually increase the risk of morbidity.

Residents discuss the sensitivity and specificity of procedures and tests, but positive and negative pre- dictive values are rarely understood [ 10,111. The Baysian concept [ 121 that the chance of a positive or negative outcome of a procedure is affected by whether the population being screened is at high risk has major clinical applications to office medical practice.

(2) Patient-physician negotiation: The most common complaint about physicians is that they do not listen. The problem is not lack of listening, it is lack of conscious negotiation and accommodation between patient and physician. After the patient’s problem has been defined, and the options narrowed, the physician and patient must reconcile their concepts of the prob- lems and its treatment [ 13,141. Unsuccessful or absent negotiations can lead to patient dissatisfaction, com- plaints of arrogance, professional unhappiness for physicians, noncompliance with prescribed regimens and doctar-shopping. Nothing, I believe, could help the pubic’s image of internists more than teaching residents how to achieve accommodation with their patients.

(3) Patient comfort and common problems: Pa- tients are not warned of the next day’s events even though anxiety is lessened when one knows in advance what will happen. Nursing and laboratory schedules do not take sleeping and eating into account. Page systems boom throughout the night. Parenteral therapy is used when oral medication will work well. Visitors are re- stricted (they are a nuisance, not an important part of

the treatment of illness). These are only a few of the legion insults we inflict on our patients’ dignity. Our puritanical attitudes that pain should be borne with dignity, or that sleeping pills are bad for you (despite our determined efforts to prevent an uninterrupted night’s Sleep), are inappropriate. Worse yet, the opinion that pain should not be relieved because it is “something to follow” despite little or no convincing evidence to support that contention, e.g., in pancreatitis or acute myocardial infarction, is a triumph of technology over human-scaled medicine.

The common afflictions-upper respiratory tract infections, ordinary rashes, musculoskeletal disor- ders-are poorly taught, if at all, to internists. The ex- perienced internist who skillfully treats the patient with diabetic ketoacidosis but tells a patient with a sore throat to gargle with salt water (what his mother taught him) is the rule, not the exception. To concentrate on the teaching of medical subspecialties at the expense of teaching management of the common illnesses robs the internist of breadth. There should be an excellent textbook for common outpatient problems on the desk in the clinic, not a PDR.

The public expects the internist to be expert in health care screening. A sound beginning to rational screening has been made [15]. It is ironic that internists and residents consistently do what has been demonstrated to be ineffective, such as routine electrocardiograms, and omit what has been proved to be valuable, such as mammograms.

(4) Psychiatry: Unquestionably the greatest shock of beginning the practice of internal medicine is how much psychiatry is involved. Anxiety, depression, psychosomatic symptoms, marital discord and de- pendence on alcohol, cigarettes and psychoactive drugs constitute, as a group, the major reason for patients to consult internists. Dealing with “illness” resulting from the “medicalization of social problems” has come to rest firmly on the shoulders of the internist [ 161, yet we have not equipped him for this responsibility.

Counseling techniques are not taught, and psycho- social problems are avoided because residents believe that they do not have the time or skill to deal with them, that they are painful for the patient to discuss and that it is not an internist’s job anyway [ 171. Patients certainly do not perceive this to be the case; a receptive internist will soon encounter patients who come to see him just to talk over a job crisis or family problem.

Remarkably, the use of major psychotropic agents is not taught to residents because no specialty of in- ternal medicine consistently uses them. Yet the internist takes care of patients receiving phenothiazines, lithium or tricyclic antidepressants when medical problems develop, sometimes due to these drugs. Medical care of the elderly and retarded persons requires that this

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category of agents be used skillfully. Minor tranquilizers are a generally safe class of agents which are too im- portant to both physicians and patients to be used with the small amount of thought or imagination currently allotted them.

(5) Medical ethics: The practicing internist makes ethical decisions intuitively, introducing personal and social influences when they do not necessarily belong [ 181. The issues of patient rights to medical care, to die, to participate in decisions or to the truth are not sterile topics for philosophical discourse-they lurk in the wards, intensive care units and clinics. Bedside teaching of ethics by a physician and clinical ethicist [ 19,201 is received with enthusiasm by residents. An internist should have explored the major ethical issues and have a well-developed set of ethical concepts before he leaves his training program. Those who have not had instruction in ethics are forced to “reinvent the wheel” when they attempt to discuss these issues thoughtfully

[181. (6) Cost-effectiveness analysis: The practicing

internist faces many factors working against cost-ef- fective medical care such as pressures from patients and family, needs to keep hospital census high, drug company promotions and third party reimbursement schedules which reward expensive procedures dis- proportionately to their diagnostic value. Cost-effec- tiveness analysis, or the more comprehensive concepts of cost-benefit analysis which considers all the con- sequences of a course of action rather than just relative expense, should be an integral part of decision making. I believe the practicing internist, who must explain the costs of increasingly expensive medical care to his patients, is receptive to the ideas behind cost-effective analysis but has not been taught the skills to implement those ideas [21,22]. Simply making residents aware of medical care costs can have good economic and educational influences [23].

(7) Practice management: Internists are notor- iously bad businessmen, and many are perversely proud of their ignorance of business matters. If this affected only their income, it would be of little consequence to training programs. Good practice management, how- ever, improves physician efficiency and, therefore, can lower health care costs, teaches the appropriate use

of consultants to avoid financial and legal pitfalls, and can lower the business stresses a physician faces permitting him to devote more energy to the practice of medicine. The executive stresses of internal medi- cine are only one category of problems faced by the physician [24-261, but they are the most accessible to education through learning how to delegate non- clinical tasks. Books and seminars designed for the resident would require a miniscule amount of the time devoted to a resident’s education and yield dispropor- tionate benefits [27,28]. Some attention to manage- ment techniques, at least, is required to counteract the bad experience residents encounter in our chaotic, expensive and inefficient clinics.

Some Hopeful Signs

The firm system [29,30] incorporates general internal medicine faculty into a teaching program by assigning a firm director to subunits of the department of medicine (firms) which have their own housestaff, clinic, ward and patient population. The firm director can be responsible for including the curriculum of general internal medicine in the residents’ education, serve as role models of clinicians and engage in much needed clinical research activities.

Continuity of care is now a common goal of training programs. Residents have patients whom they follow for three years, getting to know them as persons rather than a collection of diagnoses. They learn what it means to resolve conflicts with problem patients, rather than manipulating the system to avoid them.

Clinical pharmacology, thanks to cardiology and in- fectious diseases, is better taught, although general areas like geriatric [31] or adolescent pharmacology require attention, perhaps by a general internal medi- cine department.

The curriculum of general internal medicine includes most of the major deficiencies in the education of the internist, whether generalist or subspecialist. Now that most university training programs have departments of general internal medicine, a hopeful sign indeed, it is time to decide what to do with them. Making the resi- dents’ education reflect to the needs of the practicing internists and his patients is the first priority.

REFERENCES

1. Gaffney JC, Glandon GL (eds): Profile of medical practice. Chicago: American Medical Association Publication, 1979; 161.

2. Mendenhall RC, Tarlov AR, Girard RA, Michel JK, Radecki SE: A national study of internal medicine and its subspecialties. Il. Primary care in internal medicine. Ann Intern Med 1979; 91: 275267.

3. Goroll AH, Stoeckle JD, Goldfinger SE, et al.: Residency training in primary care internal medicine. Report of an

478 September 1961 The American Journal of Medicine Volume 71

operational program (at Mass General Hospital). Ann Intern Med 1975; 63: 672-677.

4. Siegler M (ed): The general internist as a faculty member. Arch Intern Med 1977; 137: 1326-1329.

5. Eichna LW: Medical school education, 19751979. A student’s perspective. N Engl J Med 1960; 303: 727-734.

6. Goldfinger SE: Continuing education and general internal medicine. Arch Intern Med 1977; 137: 1311-1315.

7. Greenland P, Mushlin Al, Griner PF: Discrepancies between

TRAINING INTERNISTS-McCUE

knowledge and use of diagnostic studies in asymptomatic patients. J Med Educ 1979: 54: 883-889.

8. Blois MH: Clinical judgment and computers. N Engl J Med 1980; 303: 192-197.

9. Tumulty PA: The art of healing. Johns Hopkins Med J 1978; 143: 140-143.

10. Weinstein MC, Fineberg HV: Clinical decision analysis. Phil- adelphia: W. B. Saunders, 1980.

11. Galen RS, Gambino SR: Beyond normality. The predictive value and efficiency of medical diagnoses. New York: John Wiley 8 Sons, 1975.

12.

13.

14.

15.

16.

17.

18.

19.

Bayes T: An essay toward solving a problem in the doctrine of chance. Phil Trans Roy Sot 1763; 53: 370-418.

Siegler M: On the nature and limits of clinical medicine. Un- published ms.

Freidin RB, Goldman L, Cecil RR: Patient-physician concor- dance in the primary care setting. Ann Intern Med 1980; 93: 490-493.

Report of the Canadian Task Porte on periodic health ex- amination: Periodic (vs. annual) health examination. Can Med Assoc J 1979; 121: l-45.

Hamerman D: Primary care-is it here to stay? The implica- tions for medical education. Bull NY Acad Med 1979; 55: 540-550.

Duffy DL, Hamerman D, Cohen MA: Communication skills of house officers. A study in a medical clinic. Ann Intern Med 1980; 93: 354-357.

Siegler M: A legacy of Osler. Teaching clinical ethics at the bedside. JAMA 1978; 239: 951-956.

Eisenberg JM: Sociologic influences on decision-making by clinicians. Ann Intern Med 1979: 90: 957-964.

20. Thomasma DC: Medical ethics training: a clinical partnership. J Med Educ 1979; 54: 897-899.

21. Weinstein MC, Stason WB: Foundations of cost-effectiveness analysis for health and medical practices. N Engl J Med 1977; 296: 716-721.

22. Fuchs VR: What is CBAICEA, and why are they doing this to us. N Engl J f&d 1980; 303: 937-938.

23. Lyle CB, Bianchi RF, Harris JH, Wood ZL: Teaching cost containment to house officers at Charlotte Memorial Hos- pital. J Med Educ 1979: 54: 856-862.

24. McCue JD: Private practice: surviving the first year. 1981, Collamore Press (in press).

25. Denford JD: Emotional problems of doctors starting general practice. N Engl Med J 1969; 69: 136-139.

26. McCue JD, Billowitz A. Waggoner DM: A group therapy mods1 for helping medical residents deal with stress (in prepara- tion).

27. Eisenberg JM, Williams SV: The physician’s practice. New York: John Wiley & Sons, 1981.

28. Lawson JG, McConnell JW: Teaching practice management in a family practice residency. J Med Educ 1976; 51: 858-860.

29. Waggoner DM, Frengley JD. Gsiggs RC, Rammelkamp CH: A “firm” system for graduate training in general internal medicine. J Med Educ 1979; 54: 556-581.

30. McKusic VA: A plan for reorganization of the Osler Medical Service. Johns Hopkins Med J 1977; 63: 493-948.

31. Manning PR. Lee PV, Denson TA, Gilman NJ: Determining educational needs in the physician’s office. JAMA 1980; 244: 1112-1115.

September 1981 The American Journal 01 Medicine Volume 71 479