ACP can be a medical home for all aspects of internal medicine

Physicians with widely disparate backgrounds and interests can function together and share a passion for expanding primary care under the auspices of a patient-centered medical home.

Editor's Note: Dr. Luke is Chair, ACP Board of Regents, 2010-2011, and is guest-writing this month's President's Message.

ACP president J. Fred Ralston, FACP, and I, as chair of the Board of Regents, make a good tandem. His experience is in primary care, he is a former ACP governor, and he is very knowledgeable about state and federal government. My background is in academic internal medicine and nephrology; I have been involved in teaching and patient care with medical students, residents and fellows over the past four decades. I am an “IMG” from Scotland. My previous contributions to the College have been through MKSAP, the Internal Medicine In-Training Examination for residents, and other education programs.

Dr. Ralston and I are proof that physicians with widely disparate backgrounds and interests can function together and share a passion for resuscitating and expanding primary care while ensuring that ACP remains the “big tent” for internists in all aspects of internal medicine.

Fragmentation is the bane of our health care system, and we must take care that the same problem does not destroy internal medicine as an intact discipline. Internists continue to share at least three years of residency training, to care deeply about pathophysiology and mechanisms of disease, to revel in diagnostic challenges, and to take a holistic approach to patient care. Training in our discipline is the widest portal to varied careers for our graduating medical students in primary care, our subspecialties, hospitalist care, clinical and basic science, and medical leadership in general. The College can help promote an increase in entry to training in internal medicine by continuing to support reform of our health care delivery and payment system, as well as an increase in the presently frozen number of residency training positions.

Improvement in the professional environment for internists is essential for securing coordinated care of the increasing number of our patients as more of them become insured. Practicing in the patient-centered medical home (PCMH) and the medical “neighborhood,” if appropriately reimbursed, could improve integrated primary and subspecialty care for all our patients and physicians. Indeed, a subspecialty physician could sometimes participate as the principal provider in the PCMH for episodes of care, such as intensive chemotherapy for cancer, that require intense subspecialty involvement. The primary doctor would remain in the PCMH and resume leadership of care after the patient was stabilized. In some circumstances, such as chronic dialysis, the nephrologist could remain permanently as the principal provider in the PCMH if the patient so wished. In such cases, some of the savings from increased efficiency in preventive care (for example, from Medicare Part A by reducing hospital admissions and emergency care) could mitigate the potentially divisive issue of a global cap for physician payment.

The College has excellent relationships with its many members and seeks to hear their unique concerns through its governance. The College's Council of Subspecialty Societies includes representatives from 26 subspecialties and is represented on the Board of Regents by a physician selected by that council. The Subspecialty Advisory Group for Socioeconomic Affairs (SAGSA) is a similar group that focuses mainly on reimbursement issues. We are fortunate in the College to have councils of medical students and one for associates (residents and fellows), each of which has a representative chosen by them on the Board of Regents, ensuring that younger voices are heard.

ACP has much of value to offer to all internists in the areas of advocacy, efficient patient care, professionalism, education, assistance with new forms of practice, and assurance that pay-for-performance is fairly utilized. It is my hope that the Regents of the American College of Physicians, working closely with the Board of Governors, can populate our medical home for internists with a substantially increased representation from all the subgroups of our discipline. The College can act as the glue to hold the various subdisciplines of internal medicine together. All internists, however, should maintain the 30,000-feet view of what we share in training and outlook and of how important our coordinated efforts can be in improving the care of our patients.