I read and appreciated the ideas put forward by Blackwell and Powell in “Internal Medicine Reformation” (Am J Med. 2004;117:107). They made me think of the “free range chicken” offered at fancy restaurants. This neologism is applied to a free roaming animal, formerly designated “the chicken.” When the original name was appropriated by a newly developed entity, the product of a highly developed and regulated industry, the need for the neologism arose.
Blackwell and Powell believe in early and fast track career choices as a means to reawaken interest in internal medicine. I cannot help but think that this is a well-meaning attempt to return to “free-range internal medicine,” the unregulated internal medicine that prevailed before the health insurance industry and managed care organizations were born, and before the state and federal governments developed a paranoid regulatory climate for the medical profession. I would love to see free-range internal medicine prevail again, and I believe the public would too, but the emphasis in Blackwell and Powell’s solution is misplaced. Further organization and regulation of medical education, albeit in a different shape, may help somewhat but does not address the crux of the issue.
We live in a market society, in which allocation of resources and financial considerations are at the core of all enterprises. The last time I had a patient referred to me for refractory hypertension, it took me about 7 hours to gather the information (illegible notes, suboptimal computer systems, files retrieved by resorting to four subway rides between institutions), analyze it, and make a decision (no tests, one pill) that fortunately corrected the problem. If a neurosurgeon is paid several thousand dollars for an often incomplete removal of a malignant brain tumor, how much was my consult worth? According to risk calculators, I reduced the chance of a bad cardiovascular outcome by 15-fold in this patient, but I doubt her insurance coverage provided more than a 50-dollar compensation to my institution. Why would medical students in their right minds choose to do what I do, if they want to work, raise a family, and send their children to college?
Solutions such as that suggested by Blackwell and Powell must be part of a larger package that includes a revolution in the finances of health care. This will probably require that internists and primary care providers, as well as the societies that represent them, resort to civil disobedience. If we want to succeed in providing a coordinating physician for every U.S. citizen, as the public demands, we will have to tell politicians to put their dollars where their mouths are, particularly when they promise to prospective voting constituencies rosy solutions for health-care problems. I believe that the success of this approach, leading to an influx of fairly and reasonably reallocated U.S. health care dollars, is the only chance for the Texas horse to be resuscitated so that we can get back on it and ride off into the sunset.
© 2005 Elsevier Inc. Published by Elsevier Inc. All rights reserved.