I am a general internal medicine doctor, a primary care physician, and a service line director for Adult Health & Wellness in the MetroHealth System in Cleveland, Ohio. While I have always loved general internal medicine, I admit that in recent years I (like many colleagues) have struggled with an identity crisis. What does it mean to be a General Internal Medicine specialist?
I remember clearly why I chose internal medicine. I loved being the detective, the coach, the mechanic, the therapist, the problem-solver—all in a day’s work. I loved hearing people’s stories and understanding who they were as a whole and as a part of a larger system that would sometimes help and sometimes hinder them. I loved knowing at least a little bit about everything and being able to piece together this information to help people solve problems, educate them, and help them achieve their health goals. Early in my career, I would see patients in the clinic and follow them to the hospital when they got sick, and then transition them back to home and to see me in the clinic again. Over time, my work in the hospital setting decreased to a few weeks a year, and there became a growing distinction between a hospitalist and a primary care general internal medicine doctor. Primary care general internists are paid less than their hospitalist colleagues, and if payment is a sign of value and respect, primary care specialists have been on the bottom of the totem-pole for years now.
To make matters worse, the term primary care doctor gained traction, particularly after a 1978 Institute of Medicine report, A Manpower Policy for Primary Health Care: Report of a Study.1 The second chapter defined the essence of primary care as: “accessible, comprehensive, coordinated and continual care delivered by accountable providers of personal health services.” While an accurate description of care provided by general internists practicing in the ambulatory setting, the document “lumped” general internists with other primary care specialists (family medicine, ob/gyn, pediatrics). Today general internists often practice side-by-side with family medicine specialists, seeing the same complexity of patients. In some healthcare systems, we are hired inter-changeably and the distinction between specialties has become blurred, causing many internists to again wonder—what does it mean to be a general internist? Furthermore, with fewer medical graduates choosing to become primary care specialists, we rely more and more on our advanced practice nurses to meet the growing demand for primary care services. Again, we lose our identity. Are we the same and interchangeable with a family medicine doctor? Are we the same and interchangeable with a nurse practitioner? What does it mean to be a general internist? It is no wonder why junior physicians in training are not choosing primary care general internal medicine.
As stressful as the COVID-19 pandemic has been for all of us, one silver lining from this experience has been that it has brought general internal medicine into the spotlight and provided us with a renewed sense of value. While being a generalist may not have been perceived as valuable pre-COVID, in a COVID environment, being a generalist has meant that we can be flexible and can serve in many ways. When our hospital needed to set up a Dr. COVID advice hotline, who was called on to set this up and staff it? When our hospital needed to set up a telephone-based outreach for primary care access, who was called on to develop and staff it? When our hospital needed to prepare for the surge of COVID cases and deploy doctors to staff the inpatient teaching services and supplement emergency services, who was called on the staff the surge? When our hospital needed doctors to train other doctors to be diagnosticians and generalists, who was called on provide the training? The answer to all these needs was General Internal Medicine doctors.
Our training in Internal Medicine made us ideal candidates to flex from offering advice on the variety of symptoms patients with COVID might present with to caring for our sickest, hospitalized patients. Our versatility and our breadth of knowledge is our strength. This has been the silver lining in the COVID pandemic. COVID has helped to solidify the importance of general internists as leaders in healthcare. GIM docs—this is our time! May we be flexible, versatile, and adaptable in this time of incredible stress, and may we be strong, together, as General Internal Medicine.