Patient care is increasingly complex and health care delivery is increasingly fragmented.1 Primary care and hospital-based general internists are the lynchpins in our healthcare system. They see the big picture, understand what matters most to patients, coordinate care across consultants, and communicate effectively with patients and their loved ones. In the hospital, this type of care occurs in a compressed timeframe of days and weeks; however, in the outpatient setting, it occurs over a longer timeframe, often extending many years.
As healthcare complexity increases, the pipeline of trainees entering general internal medicine, especially primary care general medicine, is shrinking;2 and recruiting and retaining academic general internists to train future generations of physicians is increasingly difficult. In advocating for changes to improve our pipeline of trainees and support general internists, I am struck by how often we need to explain what we do, how it differs from specialist care, and why this type of care is more important now because of the increasing complexity of our healthcare system.
I keep returning to the “4 Cs” of primary care, first described by Barbara Starfield—a pediatrician, public health and policy leader, and vocal advocate for primary care throughout her career—to help me explain the unique characteristics of generalist care: first contact, continuity, comprehensive care, and coordinated care.3 These characteristics are the foundation of quality health care and have long been associated with improved health outcomes for patients.4
1. First contact emphasizes the importance of a general internist as the physician who knows a patient well and is the first one called about a health concern, usually by a nurse in the inpatient setting and by the patient or a family member in the outpatient setting.
2. Continuity implies having long-term relationships with patients and getting to know the whole person. Continuity builds trust with patients and provides a longitudinal perspective of patients’ health, medical conditions, and social context, which can inform decisions when new or difficult issues arise.
3. Comprehensive care means considering the full picture of a patient’s health; providing a broad range of care including preventive, acute, and chronic care; and supporting a patient when there is uncertainty about a condition, or the condition is serious and untreatable.
4. Coordination of care provides patients with a game plan for their care and ensures they receive the right care at the right time, enhancing patient safety and quality. The general internist is the quarterback for the team of specialists and others involved in a patient’s care and an advocate for patients to assure seamless and timely care in a fragmented health system. The work involved in care coordination and the importance of developing relationships with others involved in a patient’s care is well described in the article, “Instant replay—a quarterback’s view of care coordination,” by Press.5
Specialists may assert they provide care coordination and the other Cs of generalist care, but they would be hard pressed to document that they provide the care described by Press.5 More often, specialists will advise patients to talk to their generalist physician for comprehensive and coordinated care when patients raise issues perceived to be outside the scope of their specialty care (e.g., completing forms for family medical leave, addressing a flare of chronic back pain).
SGIM is working on several issues to improve support of academic general internists so we can continue to incorporate the 4 Cs into our practice and enhance our ability to attract and retain trainees. On the organization of healthcare front, SGIM is partnering with ACLGIM to work on three areas identified as high priority based on the 2023 Hess Institute report: enhance the focus on team-based care delivery, rebalance primary care compensation to align with the work at the institutional level, and improve learner experience in primary care and increase training time in this setting.
Some of the key issues identified during the Hess Institute can be traced to the discrepancy in physician payment between generalist physicians and those in procedure-based specialties. Our Health Policy Committee is taking on this broader policy challenge. The Centers for Medicare & Medicaid Service’s (CMS) issued their proposed rules for the 2024 fiscal year affording us an opportunity for advocacy on payment reform. The CMS proposed rules include starting payment for a new evaluation and management (E/M) code, G2211, which was put on hold several years ago due to concerns raised by some specialty organizations. It would provide additional funds for care coordination and continuity, an important role that generalists play. The proposed rules also open an opportunity to evaluate the current process for setting the physician fee schedule that relies on the American Medical Association’s Relative Value Scale Update Committee (RUC). CMS requests information that could lead to other methods for setting the value of E/M and other codes.
To address the needs of student, resident, and fellow SGIM members, this issue of the SGIM Forum kicks off a quarterly column dedicated to these members that will highlight resources for trainees, the challenges they face, and celebrate their successes. Second, based on the Research Committee’s report on the state of general internal medicine (GIM) fellowships and fellows, the SGIM Council appointed a seven-member GIM Fellows Task Force to address the Committee’s highest priority recommendations (see the CEO “Q&A” column in this issue). Finally, the Southern region is planning to have programming specifically for historically black colleges and universities (HBCUs) at their regional meeting again this year. SGIM’s President-elect, Jada Bussey-Jones, will continue our personal outreach to medical students, residents, and residency program directors at HBCUs who attend the regional meeting.
I will keep you posted on our progress. The work you do is more important than ever and has an impact on health outcomes. Our job is to convince our health system leaders and policy makers.