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It)TjT*-0.0148 Tc-0.0164 Tw(involves a primary obligation to advocate for and serve the specific needs of each)TjT*-0.0143 Tc-0.0169 Tw(individual patient, and a secondary obligation to serve societal interests and allo-)TjT*-0.0081 Tc-0.0231 Tw[(cate finite resources to achieve good health for the larger community \(3,12\). T)179.8(o)]TJT*-0.0053 Tc-0.0251 Tw(achieve these aspirations, internists must work in partnership with each patient)TjT*0.0781 Tw(to address his or her health care needs by examining, inquiring, researching,)TjT*-0.0157 Tc0.0408 Tw(analyzing, consulting, informing, and discussing, and then planning, coordinat-)TjT*0.0132 Tw[(ing, delivering, evaluating, and revising care. Simultaneously)79.7(, sustaining compe-)]TJT*0.0327 Tw(tence and achieving excellence in internal medicine practice require keeping up)TjT*0.0129 Tw(with the rapidly changing and expanding body of medical knowledge. )Tj1.6364 -1.0909 TD-0.0096 Tc-0.0216 Tw(In the past, these challenging demands drew the best and brightest to inter-)Tj-1.6364 -1.0909 TD-0.0053 Tc0.0152 Tw[(nal medicine for many reasons. First and foremost is the desire for long-term,)]TJT*-0.0025 Tc0.1265 Tw(trusting relationships where patients feel comfortable discussing health and)TjT*-0.0053 Tc0.0027 Tw(psychosocial issues, thus enabling an effective partnership for achieving health)TjT*-0.0157 Tc0.0304 Tw(and managing disease. Second, the intellectual challenge of maintaining knowl-)TjT*-0.0033 Tw[(edge and competence in the treatment of the whole patientŽ and the autonom)-10.2(y)]TJT*0 Tc0.124 Tw(to make independent clinical decisions are critical to attracting students to)TjT*0.0091 Tc0.1149 Tw(internal medicine and sustaining career satisfaction. Societal and collegial)TjT*-0.0053 Tc0.0244 Tw(respect and the opportunity to consult freely with specialist colleagues for the)TjT*0.0657 Tw[(benefit of patients are also important to career satisfaction. Finally)79.8(, internists)]TJT*-0.0081 Tc-0.0231 Tw[(value the role of advocate, both on behalf of individual patients and on a broad-)]TJT*-0.0053 Tc0.0779 Tw(er societal level. While earnings potential has importance, studies repeatedly)TjT*0.0072 Tw(demonstrate that non-monetary elements of professionalism determine career)TjT*-0.0054 Tc0.013 Tw(satisfaction \(4,5,13\).)Tj/F6 1 Tf12 0 0 12 91 326.3867 Tm-0.0002 Tc0.0139 Tw[(IV)119.7(.)-252(G)0(r)19.6(o)14.8(wing Challeng)-10(es to Medical Pr)19.6(of)9.6(essionalism)]TJ/F3 1 Tf11 0 0 11 127 308.3867 Tm-0.0053 Tc-0.0221 Tw(The changing social, cultural, and economic environment in which health care)TjT*0.053 Tw(is delivered has altered the traditional manner in which the contract between)TjT*0.1265 Tw(medical professionals and their patients is fulfilled. A more highly-educated)TjT*-0.0022 Tc0.1262 Tw(patient population approaches medical care from a consumerist perspective)TjT*-0.0053 Tc0.0463 Tw(and does independent research, asserts personal control, and factors cost into)TjT*-0.0171 Tc-0.0245 Tw[(health care decision making \(14\). The increased importance of patient autono)-10.3(m)-10.3(y)]TJT*-0.0053 Tc-0.0167 Tw[(and self-determination together with the evolution of a significantly more plu-)]TJT*-0.0016 Tc0.1257 Tw(ralistic society has appropriately diminished paternalistic physician decision)TjT*-0.0053 Tc-0.0087 Tw[(making. Media coverage of abuses of power)59.9(, conflicts of interest, and econom-)]TJT*0.0389 Tw[(ic insensitivity)79.8(, as well as publicity surrounding scientific and medical innova-)]TJT*0.0014 Tw(tions, institutional errors, and medical mistakes, have replaced blind faith with)TjT*0.0129 Tw(skepticism \(15,16\).)Tj1.6364 -1.0909 TD-0.0257 Tw(While a healthy dose of skepticism and more active patient participation in)Tj-1.6364 -1.0909 TD-0.0054 Tc0 Tw(the )Tj1.5831 0 TD-0.0157 Tc-0.0065 Tw(health care process are positive changes, their coincidence with ever increas-)Tj-1.5831 -1.0909 TD-0.0209 Tw[(ing corporate, insurer)59.7(, and government control over medical practice is straining)]TJT*0.0263 Tw(the application of traditional concepts of medical professionalism. The pressure)TjT*0.1094 Tw(of controlled physician reimbursement rates and rising medical practice costs,)TjT*-0.0256 Tc-0.016 Tw(together with growing administrative demands imposed by private payers and fed-)TjT*-0.0157 Tc0.0247 Tw(eral regulation is making traditional internal medicine practice more difficult to)TjT*0.1294 Tw(maintain \(17\). Confronting these challenges inevitably diverts some physician)Tj/F5 1 Tf12 0 0 12 302.5695 44.1436 Tm0 Tc0 Tw(3)TjETQendstreamendobj32 0 obj<</ProcSet [/PDF /Text ]/Font <</F3 15 0 R/F5 16 0 R/F6 24 0 R>>/ExtGState <</GS2 8 0 R/GS3 17 0 R>>>>endobj34 0 obj<</Length 5752>>stream
1 g/GS3 gs0 792 m0 792 lfq0.2 i 0 792 612 -792 re0 792 mW n0 801.015 612 -801 reW nBT/F3 1 Tf9 0 0 9 69.9869 748.1709 Tm0 0 0 1 k/GS2 gs-0.0002 Tc0.013 Tw(Medical Professionalism in the Changing Health Care Environment)Tj11 0 0 11 127 710.6533 Tm-0.0103 Tc0.124 Tw[(energy away from focusing on relationships with patients and understanding)]TJ0 -1.0909 TD-0.0151 Tc0.1288 Tw(patient needs. The increasing difficulty of achieving commonly held expecta-)TjT*-0.0157 Tc0.0532 Tw(tions of medical professionalism has contributed to dissatisfaction with medical)TjT*-0.0188 Tc-0.0228 Tw[(practice, causing established internists to subspecialize or to cut back, retire from,)]TJT*-0.0157 Tc-0.0168 Tw[(or leave their practices \(5,14,18-20\). This dissatisfaction is sending a strong mes-)]TJT*0.0792 Tw(sage to medical students and residents, causing many to forgo general internal)TjT*-0.0209 Tw(medicine for more clinically-autonomous, less time-pressured, and more highly-)TjT*0.0129 Tw(compensated, procedure-oriented specialist careers \(21-25\).)Tj/F7 1 Tf0 -2.1818 TD-0.0001 Tc0.0138 Tw[(The P)29.7(atientÐPh)19.7(ysician Relationship)]TJ/F3 1 TfT*-0.0062 Tc-0.025 Tw(A sustained long-term patient…physician relationship in which each interaction)Tj0 -1.0909 TD-0.0053 Tc0.0063 Tw(strengthens the foundation for the next is fundamental to developing the trust)TjT*0.1048 Tw(and respect required for full, open, and collaborative communication within)TjT*-0.0049 Tc0.1289 Tw[(each clinical encounter)59.7(. That communication is crucial to providing quality)]TJT*-0.0053 Tc-0.0041 Tw(health care. Despite the dramatic changes in the health care environment over)TjT*-0.0062 Tc-0.025 Tw(the past twenty years, the vast majority of Americans have demonstrated a con-)TjT*-0.0095 Tc-0.0217 Tw(sistent preference for a sustained relationship with a primary care provider \(26\).)TjT*-0.001 Tc0.1251 Tw(Recent studies suggest that the existence of a continuous patient…physician)TjT*-0.0053 Tc0.0371 Tw[(relationship may reduce emergency department use \(27\) and total health care)]TJT*0.0578 Tw(costs per patient \(28\). Furthermore, sustained patient…physician relationships)TjT*-0.0087 Tc-0.0225 Tw(correlate directly with patient compliance, improved health, positive outcomes,)TjT*-0.0053 Tc0.0129 Tw(and reduced malpractice litigation \(26\).)Tj1.6364 -1.0909 TD-0.0087 Tc-0.0225 Tw(Research has repeatedly demonstrated a strong correlation between patient)Tj-1.6364 -1.0909 TD-0.0148 Tc-0.0164 Tw(satisfaction and physician satisfaction, both with the clinical interaction and with)TjT*-0.0034 Tc0.1275 Tw(practice in general. Likewise, the degree of physician satisfaction correlates)TjT*-0.0053 Tc-0.0168 Tw(directly with the extent to which his or her patients are satisfied with their care)TjT*-0.0028 Tc0.1268 Tw(\(6,18\). Furthermore, critical medical outcomes such as accurate prescribing)TjT*-0.0053 Tc0.0016 Tw(practices, patient compliance, and high quality-of-care are all related to physi-)TjT*0.0292 Tw(cian satisfaction \(38\). It is clear that the degree to which the complex changes)TjT*0.0666 Tw(in the health care environment impede the development and maintenance of)TjT*0.012 Tw(strong, mutually-satisfying patient…physician relationships has important con-)TjT*0.0129 Tw[(sequences for health care access, quality)79.8(, and efficiency)79.7(.)]TJ1.6364 -1.0909 TD-0.1556 Tc0 Tw(Tr)Tj0.9957 0 TD-0.0157 Tc0.0808 Tw(usting, intimate relationships with patients have suffered in the evolving)Tj-2.6321 -1.0909 TD0.005 Tc0.2236 Tw(health care environment. The financial and bureaucratic complexities of )TjT*-0.0157 Tc0.0846 Tw(relationships between physicians and private and public payers are difficult for)TjT*0.005 Tc0.1349 Tw(patients to comprehend, and administrative and coverage issues can cause )TjT*-0.0227 Tc-0.0189 Tw(substantial stress within patient…physician relationships. Despite the ethical impli-)TjT*-0.0157 Tc0.0607 Tw(cations, some physicians, with their patients support, feel pressured to mislead)TjT*-0.0094 Tc0.1231 Tw(insurers to gain coverage for specific services \(29\). This is primarily because )TjT*-0.015 Tc0.1287 Tw(pursuing arduous appeals processes to obtain coverage for non-approved ser-)TjT*-0.0157 Tc-0.0192 Tw(vices has adverse consequences for both patients and physicians in that it reduces)TjT*-0.0007 Tw(time available for patient care and leaves physicians vulnerable to being dropped)TjT*-0.0228 Tw(from often crucial provider networks. Their highly publicized role as stewards of)TjT*-0.0076 Tw(limited health care resources creates further stress within patient…physician rela-)TjT*-0.0169 Tc-0.0247 Tw(tionships when physicians must say no to specific care their patients may demand)TjT*-0.0157 Tc-0.0031 Tw[(\(25,30,31\). Finally)79.7(, while the majority of physicians report being financially neu-)]TJT*0.012 Tw(tral when making treatment decisions, nearly one third of those responding to a)TjT*-0.0048 Tw(recent national survey reported not offering patients relevant services because of)TjT*-0.006 Tc0.1197 Tw[(coverage restrictions; 35 percent of those reported doing so with increasing )]TJT*-0.0157 Tc0.0129 Tw(frequency over the past five years \(32\).)Tj1.6364 -1.0909 TD-0.0053 Tc0.0901 Tw(The cumulative impact of these pressures is that many physicians report)Tj-1.6364 -1.0909 TD-0.0088 Tc-0.0224 Tw[(being perceived by patients as adversaries rather than advocates \(33\). One com-)]TJ/F5 1 Tf12 0 0 12 302.8872 44.1436 Tm0 Tc0 Tw(4)TjETQendstreamendobj35 0 obj<</ProcSet [/PDF /Text ]/Font <</F3 15 0 R/F5 16 0 R/F7 25 0 R>>/ExtGState <</GS2 8 0 R/GS3 17 0 R>>>>endobj37 0 obj<</Length 5961>>stream
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T)34.7(ies between)]TJT*-0.0015 Tc0.1256 Tw(provider networks and both physicians and patients are tenuous, subject to)TjT*-0.0053 Tc0.0759 Tw(interruption at any time due to business decisions, contract negotiations, job)TjT*0.1112 Tw(changes, employee benefit plan changes, etc. As many as one in six patients)TjT*-0.0122 Tc0.1259 Tw[(change insurance coverage each year)59.6(, often forcing a change in primary care)]TJT*-0.0003 Tc0.114 Tw[(physician \(35\). T)179.8(wenty-five to 30 percent of managed care enrollees report )]TJT*-0.0148 Tc0.1285 Tw(experiencing discontinuity with their primary care physicians within a two to)TjT*-0.0176 Tc-0.024 Tw(three year period \(30\). The growing ranks of physician employees versus practice)TjT*-0.0157 Tc0.1175 Tw(owners leave patients more vulnerable to physician turnover due to employer)TjT*-0.0053 Tc0.0129 Tw(business decisions or physician dissatisfaction.)Tj1.6364 -1.0909 TD0.1174 Tw(Generalist physicians are increasingly concerned about health care frag-)Tj-1.6364 -1.0909 TD-0.0024 Tc0 Tw(me)Tj1.2916 0 TD-0.0126 Tc0.1263 Tw(ntation and its impact on quality care and patient…physician relationships.)Tj-1.2916 -1.0909 TD-0.0251 Tc-0.0165 Tw[(While the delegation of routine care and physical exams to nurse practitioners and)]TJT*-0.0091 Tc0.1228 Tw(physician assistants may be an efficient, effective means of allocating limited)TjT*-0.0157 Tc0.0258 Tw(resources, it must be done appropriately in order to avoid distancing the gener-)TjT*-0.0209 Tc-0.0207 Tw(alist physician from his or her patients \(4,25\). As patients rely increasingly on sub-)TjT*-0.0157 Tc0.0721 Tw(specialty care, coordination and collaboration between primary care physicians)TjT*0.0983 Tw(and specialists often falls short of preserving continuity of care \(18,25\). While )TjT*0.1054 Tw[(the growing hospitalist movement is having a positive impact on the cost and)]TJT*0.1171 Tw(quality of inpatient care, it can best serve patient needs and protect physician )TjT*0.0779 Tw(satisfaction only if effective professional communication fosters the continuing)TjT*-0.0195 Tc-0.0221 Tw(involvement of primary care physicians in their patients hospital care. And, while)TjT*-0.0157 Tc-0.0223 Tw(spending less time in patient interaction and relying more heavily on scans or lab)TjT*-0.0214 Tc-0.0202 Tw(tests may be more time efficient, the potential imbalance between technology and)TjT*-0.0157 Tc0.0103 Tw(the art of physical examination and patient interaction raises quality-of-care and)TjT*-0.0252 Tc-0.0164 Tw[(ethics concerns \(36\). The potential impact of these developments on the internist)109.7(s)]TJT*-0.0157 Tc0.0562 Tw(historic strength in treating the whole patient, across both time and settings, is)TjT*0 Tw[(unclear)59.7(.)]TJ1.6364 -1.0909 TD0.048 Tw(Whether direct from clinic administrators or the indirect result of decreas-)Tj-1.6364 -1.0909 TD0.0568 Tw[(ing reimbursement rates per clinical interaction, perceived pressure to fit more)]TJT*-0.0217 Tw(patient visits into shorter time intervals is having a significant negative impact on)TjT*-0.0123 Tc0.126 Tw(patient…physician relationships and on career satisfaction \(7,18,37-39\). While)TjT*-0.0157 Tc0.0009 Tw(time pressures are a source of dissatisfaction in many fields, the problem is com-)TjT*0.0471 Tw(pounded for general internists whose primary role is providing comprehensive,)TjT*0.1268 Tw(integrated care \(34\). This issue will become even more troublesome with the)TjT*0.0404 Tw(aging of the population and the critical role internists play in diagnosing, treat-)TjT*-0.0185 Tc-0.0231 Tw(ing, and managing the complex, chronic conditions affecting older adults \(40,41\).)TjT*-0.0157 Tc-0.0109 Tw(One study found that, while specialists spent an average of 51 minutes on a new-)TjT*0.0242 Tw(patient visit to focus on a single organ or system, general internists were able to)TjT*-0.0211 Tc-0.0205 Tw[(spend an average of only 39 minutes to build the foundation for a long-term ther-)]TJT*-0.0157 Tc0.0048 Tw(apeutic relationship with a new patient; conduct a complete history and physical)TjT*-0.0162 Tc-0.0254 Tw(exam; provide routine screenings and preventive care; provide counseling; assess,)TjT*-0.0157 Tc-0.0005 Tw(discuss, and define treatment plans for multiple problems; evaluate relevant psy-)TjT*0.0131 Tw(chosocial factors; discuss the risks, benefits, and potential treatment interactions)TjT*0.0294 Tw(of relevant alternative and complementary medicines and; address any coverage)TjT*0.0129 Tw(issues related to new and ongoing treatment \(4\).)Tj1.6364 -1.0909 TD-0.0053 Tc-0.0047 Tw(In stark contrast to physician perceptions, studies indicate that the average)Tj-1.6364 -1.0909 TD0.0846 Tw[(time-per)34.8(-patient visit has increased over the years, regardless of whether the)]TJ/F5 1 Tf12 0 0 12 302.5695 44.1436 Tm0 Tc0 Tw(5)TjETQendstreamendobj38 0 obj<</ProcSet [/PDF /Text ]/Font <</F3 15 0 R/F5 16 0 R>>/ExtGState <</GS2 8 0 R/GS3 17 0 R>>>>endobj40 0 obj<</Length 5374>>stream
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T)34.8(ime pressures most likely)]TJT*0.06 Tw(stem from a variety of issues including: the growing health demands of a more)TjT*-0.0144 Tc0.1281 Tw(informed patient population; the complexity of choosing among varied treat-)TjT*0.005 Tc0.1209 Tw(ment options for each condition; the level of communication required for )TjT*-0.0157 Tc0.0096 Tw(collaborative decision making; the ever expanding standards for preventive care;)TjT*0.091 Tw(the impact of direct-to-consumer advertising of prescription drugs; and media)TjT*-0.0053 Tc0.121 Tw(coverage of medical innovations and the proliferation of health information)TjT*0.0154 Tc0.1322 Tw(readily available on the internet \(14,37\). While patients need to be well)TjT*-0.0053 Tc-0.02 Tw(informed about financial and coverage issues relating to treatment options, the)TjT*-0.0205 Tw(need to advocate for and inform each patient of those issues also contributes to)TjT*0.0129 Tw(time pressure within clinical encounters \(12,37\).)Tj1.6364 -1.0909 TD0 Tc0 Tw(T)Tj0.7377 0 TD-0.0053 Tc0.0164 Tw(ime pressures, whether real or perceived, can manifest themselves in the)Tj-2.3741 -1.0909 TD0.0129 Tw[(physician)109.8(s attitude and behavior within the clinical interaction as:)]TJ2.1818 -2.3134 TD0 Tc0 Tw(€)Tj1.0909 0 TD-0.0002 Tc0.013 Tw(Interrupting the patient and controlling the agenda;)Tj-1.0909 -1.0909 TD0 Tc0 Tw(€)Tj1.0909 0 TD-0.0002 Tc0.013 Tw(Impatient, rushed manner impeding collaborative exchange;)Tj-1.0909 -1.0909 TD[(€ )-300.5(Less attention to critical psycho-social issues;)]TJT*[(€ )-300.5(Less active listening; )]TJT*0.0789 Tw[(€ )-234.6(Diminished ability to demonstrate respect, advocacy)79.6(, and loyalty for)]TJ1.0909 -1.0909 TD0.013 Tw(the patient;)Tj-1.0909 -1.0909 TD0.11 Tw[(€ )-203.5(Limited opportunity to honor patient autonomy and share decision)]TJ1.0909 -1.0909 TD0 Tw(making;)Tj-1.0909 -1.0909 TD0.0527 Tw[(€ )-260.8(Limited ability to adequately prepare patients to give truly informed)]TJ1.0909 -1.0909 TD0 Tw(consent;)Tj-1.0909 -1.0909 TD-0.0001 Tc-0.0152 Tw[(€ )-328.6(Inadequate discussion of advance care planning and end-of-life issues;)]TJT*-0.0002 Tc0.0616 Tw[(€ )-251.9(Diminished ability to treat each patient as a unique and valued indi-)]TJ1.0909 -1.0909 TD0 Tw(vidual.)Tj-1.6364 -2.3134 TD-0.0053 Tc-0.0011 Tw[(Unfortunately)79.7(, the cumulative effect is diminished quality of care and a far)]TJ-1.6364 -1.0909 TD0.0129 Tw(less satisfying relationship for both patient and physician \(37\).)Tj/F7 1 Tf0 -2.1818 TD-0.0001 Tc0.0138 Tw[(Ex)9.7(er)19.7(cising Clinical J)19.7(udgment)]TJ/F3 1 TfT*-0.012 Tc-0.0192 Tw(The ability to exercise independent clinical judgment has also been strained sig-)Tj0 -1.0909 TD-0.0053 Tc0.062 Tw(nificantly by the complex changes in the health care environme)Tj26.8738 0 TD-0.0157 Tc(nt. Physicians)Tj-26.8738 -1.0909 TD-0.0243 Tw(almost universally report a loss of control over every aspect of practice, including)TjT*-0.0241 Tw(clinical decision-making, access to medically necessary services for patients, free-)TjT*0.0017 Tw(dom to spend adequate time with patients and to maintain ongoing patient rela-)TjT*0.0912 Tw(tionships, and ability to consult freely with other physicians \(4-6,18,20,43-45\).)TjT*-0.0167 Tc-0.0249 Tw(Direct-to-consumer advertising that results in patient demands for specific treat-)TjT*-0.0157 Tc0.0203 Tw(ments that may not be appropriate has strained both the patient…physician rela-)TjT*-0.0076 Tc0.1213 Tw[(tionship and independent clinical decision-making \(14,46\). While physicians)]TJT*-0.0157 Tc0.0234 Tw(appreciate the potential cost savings of restricted formularies, the sheer number)TjT*-0.0136 Tc0.1273 Tw(of different formularies confronting them and the variable co)Tj25.9669 0 TD-0.0032 Tc(mplexity of the)Tj-25.9669 -1.0909 TD-0.0053 Tc0.0489 Tw(restrictions strain physician autonomy to choose what is best for each patient)TjT*0.0129 Tw(and add substantial administrative burden to physician practices.)Tj1.6364 -1.0909 TD-0.0157 Tc0.0213 Tw(These complex challenges to traditional concepts of clinical autonomy con-)Tj-1.6364 -1.0909 TD0.0775 Tw(stitute the single strongest predictor of career dissatisfaction among physicians)TjT*0.0767 Tw(\(5,18,20\), accounting in large part for a 50 percent increase between 1996 and)TjT*-0.014 Tc0.1277 Tw(1999 in the number of primary care physicians reporting being somewhat to)Tj/F5 1 Tf12 0 0 12 302.8872 44.1436 Tm0 Tc0 Tw(6)TjETQendstreamendobj41 0 obj<</ProcSet [/PDF /Text ]/Font <</F3 15 0 R/F5 16 0 R/F7 25 0 R>>/ExtGState <</GS2 8 0 R/GS3 17 0 R>>>>endobj43 0 obj<</Length 5511>>stream
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In fact, in one study of physician satisfaction, the)Tj0 -1.0909 TD-0.0142 Tc0.1279 Tw(negative impact of health care environment changes on physician satisfaction)TjT*-0.0157 Tc0.0129 Tw(disappeared after controlling for their effect on professional autonomy \(20\). )Tj/F7 1 Tf0 -2.1818 TD-0.0001 Tc0 Tw[(Kno)14.8(wledg)-9.9(e/Competence/Excellence)]TJ/F3 1 TfT*-0.0053 Tc0.016 Tw(Ongoing changes in the health care environment bring multiple challenges to)Tj0 -1.0909 TD-0.0017 Tc0.1258 Tw(bear on professional obligations to maintain up-to-date medical knowledge)TjT*-0.0053 Tc0.0525 Tw(and skills and to advance, share, and consistently implement appropriate new)TjT*-0.001 Tc0.1251 Tw(knowledge in order to foster excellence in health care delivery \(10\). These)TjT*-0.0053 Tc0.0257 Tw(challenges are especially rigorous for internists, whose strength is their ability)TjT*-0.0032 Tc0.1273 Tw(to evaluate and thoughtfully integrate medical and social histories, directed)TjT*-0.008 Tc-0.0232 Tw[(physical exams, and results of carefully chosen tests and then apply a broad cur-)]TJT*-0.0144 Tc-0.0168 Tw(rent knowledge base to diagnose and develop tailored therapies for patients with)TjT*-0.0111 Tc-0.0201 Tw(multiple, complex diseases. Maintaining this skill set will be increasingly impor-)TjT*-0.0053 Tc0.0183 Tw(tant as the aging population seeks coordinated care for the chronic conditions)TjT*-0.0049 Tc0.1289 Tw(affecting older adults. Providing that care requires research, contemplation,)TjT*0.0154 Tc0.378 Tw(comprehensiveness, analysis, and a dedication to developing trusting)TjT*-0.0053 Tc0.0129 Tw(patient…physician relationships, all of which take time \(2\).)Tj1.6364 -1.0909 TD-0.0099 Tc-0.0213 Tw(The time pressures discussed earlier also limit internists options for engag-)Tj-1.6364 -1.0909 TD-0.006 Tc-0.0252 Tw(ing in research, teaching activities, and professional interaction with colleagues)TjT*-0.0053 Tc0.0756 Tw[(\(10\). The trend toward hospitalists providing acute inpatient care can isolate)]TJT*-0.007 Tc-0.0242 Tw(general internists within their offices, further limiting valuable interaction with)TjT*-0.0053 Tc0.0241 Tw(specialists and other professionals within the hospital setting. In addition, this)TjT*-0.0063 Tc-0.0249 Tw(isolation can contribute to generalist dissatisfaction by exacerbating conflicting)TjT*0.0154 Tc0.1489 Tw(perceptions between generalists and their procedure-oriented colleagues)TjT*-0.0053 Tc0.0129 Tw(regarding relative professional status \(4\).)Tj/F7 1 Tf0 -2.1818 TD-0.0001 Tc0.0138 Tw[(Ad)14.8(v)29.8(ocac)9.7(y and Social Responsibility)]TJ/F3 1 TfT*0 Tc0 Tw(T)Tj0.5823 0 TD-0.0157 Tc0.0262 Tw[(oday)109.7(s health care environment makes the physician)109.7(s role as advocate for each)]TJ-0.5823 -1.0909 TD-0.005 Tw(individual patient significantly more challenging. Financial disincentives regard-)TjT*0.052 Tw(ing referrals for specialist consults, diagnostic testing, and procedures, together)TjT*0.1088 Tw(with limitations on the pool of physicians, hospitals, and services available for)TjT*0.0436 Tw[(referral can restrict the physician)109.7(s ability to provide each patient with access to)]TJT*-0.0163 Tc-0.0253 Tw[(the most ap)-10.4(p)-10.4(r)]TJ5.6195 0 TD-0.0058 Tc(opriate diagnostic and treatment options for his or her condition.)Tj-5.6195 -1.0909 TD-0.0053 Tc-0.0202 Tw(Cumbersome procedures for obtaining approvals or certifications or appealing)TjT*0.0765 Tw(coverage denials can be time consuming and divert precious time away from)TjT*-0.0054 Tc0.013 Tw(direct patient care. )Tj1.6364 -1.0909 TD-0.0053 Tc0.029 Tw[(Fortunately)79.7(, recent tracking of pro bono care shows little or no decline in)]TJ-1.6364 -1.0909 TD0.0405 Tw[(the overall level of charity medical care provided \(47\) and a recent study esti-)]TJT*0.0881 Tw(mated that 91ºÚÁÏÍø-member internists in private, office-based practices provide)TjT*-0.0081 Tc-0.0231 Tw(approximately 2.6 million hours of care \(10.2 million patient visits\) to the unin-)TjT*-0.0053 Tc0.0231 Tw[(sured annually)79.8(. However)59.7(, the changing health care environment will continue)]TJT*-0.0023 Tc0.1263 Tw(to pressure physicians to cut back on or discontinue providing charity care)TjT*-0.0053 Tc0.0384 Tw[(\(48\). Payer)34.8(-imposed price discipline severely restricts the ability to cross-sub-)]TJT*0.0751 Tw(sidize charity care, and the risk of exclusion from crucial payer contracts is a)TjT*-0.014 Tc-0.0172 Tw(strong disincentive to serving a high percentage of uninsured patients. Internists)TjT*-0.0053 Tc-0.0002 Tw(with ownership in solo or small-group practices provide the most charity care,)TjT*0.0056 Tc0.1184 Tw(primarily because they have the discretion to accommodate those patients)TjT*0.0051 Tc0.1189 Tw(unable to pay \(48\). Consolidation into larger corporate or hospital-owned )TjT*-0.0054 Tc0.013 Tw[(practices restricts that discretion \(49\).)]TJETQendstreamendobj44 0 obj<</ProcSet [/PDF /Text ]/Font <</F3 15 0 R/F5 16 0 R/F7 25 0 R>>/ExtGState <</GS2 8 0 R/GS3 17 0 R>>>>endobj46 0 obj<</Length 5729>>stream
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As a result, it may no longer be clear to internists, their patients, pay-)TjT*-0.0188 Tc-0.0228 Tw(ers, and colleagues exactly what role internal medicine is uniquely able to fill \(51\).)TjT*-0.0157 Tc0.0999 Tw(Revitalizing internal medicine will require defining a shared vision of the role)TjT*-0.0233 Tc-0.0183 Tw(internists should play in providing quality patient care. Developing that vision will)TjT*-0.0157 Tc0 Tw(require:)Tj2.1818 -2.3134 TD0 Tc(€)Tj1.0909 0 TD-0.0002 Tc0.1231 Tw(Examining what adult patients want and need from the health care)Tj0 -1.0909 TD0.013 Tw(delivery system;)Tj-1.0909 -1.0909 TD0 Tc0 Tw(€)Tj1.0909 0 TD-0.0001 Tc0.0803 Tw(Assessing the skills and expertise of both general internists and sub-)Tj0 -1.0909 TD-0.0002 Tc0 Tw(specialists;)Tj-1.0909 -1.0909 TD0 Tc(€)Tj1.0909 0 TD-0.0002 Tc0.001 Tw(Defining a strategy by which internists can direct their talents toward)Tj0 -1.0909 TD0.1258 Tw(providing the integrated, comprehensive care adults want and need)TjT*0.013 Tw(across the aging continuum.)Tj-1.6364 -2.3134 TD-0.0053 Tc0.0291 Tw[(The shared vision of internal medicine should build upon the profession)109.8(s)]TJ-1.6364 -1.0909 TD-0.0054 Tc0 Tw(str)Tj1.076 0 TD(e)Tj0.4577 0 TD-0.0002 Tc0.0427 Tw(ngth as an integrating, cognitive specialty and its knowledge base in pre-)Tj-1.5337 -1.0909 TD0.0227 Tw(venting, diagnosing, and treating complex conditions \(52\). It must be consis-)TjT*0.072 Tw[(tent with the profession)109.7(s traditional dedication to providing comprehensive)]TJT*0.0206 Tc0.1761 Tw(care for the whole person, investing in strong, sustained, collaborative)TjT*-0.0002 Tc0.013 Tw(patient…physician relationships and being patient advocates \(3\).)Tj1.6364 -1.0909 TD0.0224 Tw[(While internists possess the diagnostic and preventive skills important to)]TJ-1.6364 -1.0909 TD0.0356 Tw(healthier young and middle-aged adults, their skills are especially relevant in)TjT*-0.0013 Tc-0.0247 Tw(caring for older patients with multiple diagnoses, which must be viewed in the)TjT*-0.0002 Tc0.0614 Tw(aggregate in order to accurately assess and meet health care needs. Between)TjT*0.0497 Tw(2000 and 2030, the number of Americans over age 85 will increase from 4.2)TjT*0.0194 Tc0.1098 Tw(to nearly 9 million and the challenge of caring for elderly patients with )TjT*-0.0002 Tc0.0517 Tw[(multiple chronic illnesses will soon be one of the major issues in health care)]TJT*0.1178 Tw(delivery \(53\). This patient population requires a coordinated, big pictureŽ)TjT*-0.0081 Tw(approach to complex care, including curative and palliative treatments to stall)TjT*-0.0008 Tc-0.0252 Tw[(disease progression and relieve symptoms as well as coordinated specialty care)]TJT*-0.0095 Tc-0.0165 Tw(to enable maximum daily functioning and quality of life \(54\). General internists)TjT*-0.0002 Tc0.1219 Tw(and their subspecialist colleagues, working in partnership, can provide that)TjT*0 Tw(care.)Tj1.6364 -1.0909 TD0.1146 Tw(Internal medicine has an opportunity to replace the trend toward frag-)Tj-1.6364 -1.0909 TD-0.0011 Tw(mented, episodic health care with a coordinated team approach to promoting)TjT*0.0398 Tw(health, preventing disease, managing complex chronic conditions, and facili-)TjT*0.0168 Tc0.1124 Tw(tating maximum functioning and independence throughout life. General)TjT*-0.01 Tc-0.016 Tw(internists and subspecialists can build upon the concept of Doctors for AdultsŽ)TjT*-0.0002 Tc0.0245 Tw(by making a joint commitment to improving communication and working in)TjT*0.0192 Tw(partnership towards maximizing patient health. 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