General internal medicine might seem like an awfully vague term. But assuming the health care reform bill signed by President Obama in March will be fully implemented, the general internists will finally have their day. Many of the bill’s provisions are focused on a reshuffling of the American medical landscape, which is currently dominated by sub-specialists focused on one organ system. In recent years, fewer medical students have chosen to pursue lower-paid and less glamorous careers in internal medicine, leaving a worrisome shortage in primary care doctors and hospitalists just as 32 million uninsured Americans are about to go on the books. The spotlight is about to focus on internal medicine.
“About time,” would probably be the response from most of the doctors assembled in Minneapolis last week for the 2010 Society for General Internal Medicine national meeting. Over three days, thousands of internists met in discussion groups and research panels to chart the course for a new age of American medicine. Though some fears were expressed about how an already overwhelmed system would be able to deal with the new influx of patients, the conference was more focused on seizing the opportunity to rehabilitate U.S. primary care and bring medical services to those who are traditionally underserved. The urgency of the moment was expressed right in the caps-lock and exclamation point of the meeting’s theme: “Value(s)-based generalism: THE TIME IS NOW!”
Of course, many of these efforts to expand the net of primary care didn’t start when Obama used 22 pens to sign the health care bill on March 23rd. Many of the presentations by University of Chicago faculty at the conference discussed pilot programs already being tested to improve the care of those who have traditionally fallen through the health care cracks, efforts to reduce disparity that may be instructive as the reform measures fall into place.
A workshop moderated by Marshall Chin, professor of medicine, presented four examples of programs funded by Finding Answers, Chin’s Robert Wood Johnson Foundation-supported group for studying racial and ethnic health disparities. Chin said the mission was to “evaluate interventions that reduce racial and ethnic disparities,” and the short presentations showed the breadth of that mission. Projects using cultural awareness training, electronic medical record software, and pay-for-performance programs were all discussed as potential solutions, with researchers from Harvard, Brigham and Women’s Hospital and Baylor outlining projects currently underway. One fascinating approach, described by Barbara Turner from Penn, employed African-American patients who had successfully controlled their high blood pressure as “peer coaches” to help fellow patients struggling to adhere to treatment – an elegant way of using community bonds to spread healthy messages.
Another successful example of community health intervention was presented in tandem by Deborah Burnet, section chief of internal medicine at the Medical Center, and Lorri McClinton-Powell, a teacher from Woodlawn Elementary School on the southeast side of Chicago. Last year, Burnet and colleagues conducted a pilot study of the POWER-UP program, an anti-obesity effort based around after-school activities for children and parents, with 40 children and their parents at Woodlawn. Fourteen weekly sessions – focused on themes such as “Muscle Mania” and “Stop & Shop” – taught the children about healthy eating, exercise, and behavior at restaurants and grocery stores. Though small, the study’s results held promise, with declines in overall body mass index among all but the heaviest kids at baseline. The group is currently working with Chicago Public Schools on the possibility of expanding the program for a larger study, Burnet said.
While some researchers focused on delivering primary care, others focused on educating the next generation of those who would be executing its delivery. Vineet Arora, the associate program director for the internal medicine residency at the Medical Center, presented about resident work hours, an area of her research we’ve highlighted before. Arora’s study, a collaboration with researchers from the Mayo Clinic and the Medical College of Wisconsin, reviewed literature about how residents spent their time before and after the 2003 restrictions that limited their work time to an average of 80 hours per week. Before the restrictions, proponents argued that most of the lost time would come out of residents’ “scut work” – the time spent doing menial tasks like paperwork and blood draws – rather than time gaining experience in more complex procedures and decision-making. But Arora’s analysis found the opposite, with direct patient care down and administrative work up since the restrictions went into effect. With further work hour restrictions currently under discussion, Arora said that the content of a resident’s shift, not just the length, should be considered.
In the meeting’s poster session, two of those residents from the University of Chicago presented clinical case studies significant in their own medical education. Posters in the session featured an unusual case, where the correct diagnosis of a patient required unorthodox thinking, and medical interns Roderick Deano and Ryan Dunn each presented vivid examples of looking beyond the obvious. Deano’s poster discussed a patient that was initially thought to be suffering from a “lupus flare,” but was later discovered to have ischemic colitis, a loss of blood flow to the colon unrelated to her chronic disease. The lesson? “Don’t forget the basics,” Deano said. Dunn’s poster also illustrated the hazards of making assumptions, in this case with HIV patients who contract lymphoma. Though patients with HIV are classically seen to co-present with the “non-Hodgkins” form of the lymph node cancer, a patient seen by Dunn and colleagues was determined (after many tests) to have Hodgkin’s lymphoma. That may reflect a broader trend in HIV patients, Dunn said, who appear increasingly susceptible to Hodgkin’s lymphoma with the success of HAART therapy.
At another poster session focused on research projects, instructor of medicine Valerie Press presented two side-by-side posters on educating patients with respiratory disease on correct use of inhalers – a larger problem than one might think. Press said that 62 percent of people suffering from COPD or asthma were hospitalized in the past year, many with near-fatal events that could have been avoided with proper inhaler use. So Press and her colleagues created a step-by-step instruction that doctors can use as a teaching exercise with patients who are hospitalized, an instruction that she hopes can be adapted into a video for patient education.
From small, focused interventions like that system to wider efforts to address obesity and hypertension in underserved communities, the SGIM meeting showcased a field that’s actively searching for effective and flexible solutions to health problems. While it’s too early to forecast how many of these interventions will be ultimately successful, not to mention which will receive the financial and political support to get the chance to thrive, the shortage of internists was clearly not leading to a shortage of ideas. Good news, for an American health care system at a turning point.