The Internist of 2023
What is internal medicine practice in 2023? Largely inpatient, it seems. Though patients generally spend 99.999% of their time outside of hospitals. The younger internal medicine residency graduates mostly trained in hospitals are staying to work in hospitals. The split between inpatient and outpatient internal medicine practice was well underway at the turn of the century. It took until my own stage 1 breast cancer diagnosis in 2009, the year this blog began, for me to finally let go of rounding on my own patients who were hospitalized. It is hard to imagine the ten years before then. When I first started in practice in 2009, I began each early morning with the question or the recollection of a middle-of-the-night phone call. Would I need to reroute to hospital in order to manage an admission before heading to work or could I go straight there to start seeing patients for the day?
The first seven years of my career involved a twenty-five minute commute to and from work, and I had a good day on the days I was able to make it home by the end of the evening news. Other evenings were spent at the bedside of my patient.
A lot has changed since then. As much as new healthcare delivery models and payment systems have come along to try to make outpatient practice work better, the degree of responsibility and pace of practice has actually increased. The work has increased, making the previous life of hospital rounds in addition to outpatient work seem unimaginable. Doctors like me who are still in independent practice have needed to become CEOs managing multi-disciplinary teams while also serving as the first contact in healthcare for thousands of patients.
My early mornings are more predictable, mostly spent in mental preparation for a day at the practice. Evenings at the hospital have been replaced by mixed variety of televisits, telephone consults, feeding and walking the dog, reviewing notes and documents and lab results, and sometimes meetings.
As our younger counterparts are making the case for physician wellness and work-life balance, a lot of us mid-career-and-beyond docs reflect upon how hard we have had to strive to keep our own health and personal relationships intact in the face of the increasing demands of our profession. While keeping our patients' needs at the center of every interaction, we also have to account for the needs of our staff and our next patient on the schedule. Our own needs may finally come into focus as the day comes to a close: a headache or stomach pain we have ignored or the weariness we pushed past or an overheated feeling of anxiety of one-to-many sequence changes, a heavy heart after hearing a hard story, or simply dehydration after working behind a mask all day.
We are taking care of patients in the outpatient setting with conditions which used to merit hospitalization: blood clots in the legs or even minor clots in the lungs, heart rhythm disturbances, head injuries, delirium, and other complex acute illnesses. This is both a challenge and a joy in the sense that we are able to help our patients and avoid unnecessary hospitalizations and emergency department visits. A lot of our patients with dementia or severe frailty are able to receive care at home, with our testing and treatment plans tailored to their values and preferences. It is an exciting time to prectice medicine.
Advanced technologies provide us with more insight into the workings of the human body, along with more test results to follow up. Mostly, though, the diagnoses of importance are still made by simply listening to the story. This requires time which we feel we don't always have. I am often trying to make time - cut lunch a little short, hope my dog can hold out until I get home a little later than I expected, or borrow a little time some other way. I've become a "no"-sayer when it comes to the multiplication of meetings I am offered, setting stronger limits and delegating responsibility to team members.
Like the rest of the world, we have struggled with staffing during the pandemic. We have had a very long quest for a nurse care manager who will be the best fit for our patients and practice team. We see the tremendous value of care management, but like the young doctors, so many young nurses trained almost entirely in hospital settings and get their first jobs working in hospitals. We have been searching for a year. I have been networking and advertising to bring in a new physician to the practice for nearly two years.
Meanwhile, the healthcare system has taken on a new life of its own. The pandemic is still not resolved, with looming questions about new variants and new vaccines, about the state of the public health emergency and its effects on TeleVisits, and many other variables. It has been harder to access urgent specialist appointments for patients in need. We are really hoping specialists catch on to same-day or next-day appointments! We also hope specialists will capture the wisdom of patient-centered care and be more willing to customize treatment plans and testing around the patients' goals, especially near the end of life.
As an internist, I feel obligated to advocate for a better healthcare system. I feel frustrated by the high cost of prescription medications and senseless and seemingly endless insurance company authorizations. Some medications remain out-of-reach for patients in need. I don't want to have to justify good medical decisions to someone on the other end of a phone line who is not practicing medicine. I find that though the Affordable Care Act (ACA) was a huge step in the right direction, providing insurance to tens of millions of people, the high deductible plans still make it hard for many people to afford the healthcare they need. In hindsight, there were too many concessions to the insurance industry. Today came the sad news that a federal judge in Texas ruled the preventive services coverage requirement of the ACA to be unconstitutional. While this is sure to be appealed, it is disheartening to see something we fought so hard and so long to achieve being chewed up in the court system.
Earlier this month, I joined fellow physicians at the State House testifying to the Senate and House of Delegates to oppose physician-assisted suicide (a.k.a. "The End-of-Life Options Act"). Thankfully, this legislation did not make it through crossover day. Last night, I was in a meeting with other members of the Maryland Chapter of the American College of Physicians to discuss and debate which resolutions to support to our national organization. Being part of the health policy committee has been a remedy for burnout, as we not only see the problems in healthcare but can work to do something about them.
