I have spent most of the past 2 weeks on the road – first at ACP and this week at SGIM. I have talked with many internists, but several conversations have contributed to writing this post. Each of several leaders contributed to these ideas, but I will keep them anonymous so the innocent are protected.

Here are the main assumptions:

1. Internists by training excel in the care of complexity
2. Pursuing the label of primary care back in the 1980s was a major mistake
3. Hospital medicine exists for the benefit of true primary care physicians, because they do not have enough patients hospitalized to make the trip to the hospital worthwhile

I have no objections to those internists who want to continue the primary care strategy. However, we should follow the British Empire model and fully develop the consultant model. What do I mean by the consultant model?

I believe that we should support the development of a specific type of outpatient internist, one who handles complex patients as their main task. They could do just outpatient consultation and work closely with a hospitalist group, or they could be duelists. They would receive many referrals from hospitalists, and some from primary care physicians.

These consultants could give advice to primary care physicians on balancing the care of complex patients, or they could assume total care. Now we would have to develop a more rational payment system to support these consultants.

Many retainer practices serve this function. I have two friends in Birmingham who have a small retainer practice that fits this definition. They have markedly restricted their practice and have predominantly complex sick patients. They work with the hospitalist group, and they come to the hospital to insure excellent transitions and continuity.

Consultant internists would be experts in all the major chronic diseases – e.g., CHF, COPD, cirrhosis, diabetes, CKD – and their interactions.

If we could design this job properly (and some have done this), we would have improved outpatient care and decreased inpatient care. Obviously our current RBRVS system will not support this model, but I would favor some major demonstration projects to define the appropriate panel size and cost.

Those who enter internal medicine generally accept and enjoy complexity. I believe that we could define the consultant job in such a way as to make it a highly desirable job. It might help primary care physicians who find such patients time sinks.

So, in summary, I believe we should consider dividing outpatient internal medicine into two tracks – consultant and primary care. Now I am ready for both supporting and attacking comments.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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