Introduction
Some years ago, the generalist physician was viewed
as a dying breed. This perception was attributed to an overemphasis on
inpatient subspecialty care and inadequate exposure of students and house
staff to primary and ambulatory care settings. Internal medicine clerkships
were often viewed negatively, and good role models were scarce.
1
Many clinical faculty members with whom students and house staff worked
were dissatisfied with the perception of the general internist by their
peers and with the financial disparity with subspecialist colleagues. The
overwhelming number of seriously ill patients encountered in general internal
medicine programs also diminished the enthusiasm of students and house
staff.
2
In recent years, however, due to the influences of
health care reform and the prominence of managed care, the role of the
primary care physician has regained prestige. Medical schools are encouraging
careers in primary care and are arranging preceptorships with primary care
physicians during the first and second years of medical school.
The general internist, though considered a primary
care physician, may participate in diversified career options. In private
practices, most function as gatekeepers and primary clinicians. Many now
have practices consisting primarily of elderly patients, and although without
specialty training in the geriatric discipline, those generalists with
this type of practice have gained experience and expertise not afforded
to colleagues who do not treat this population. Some general internists
are involved in traditional medical school faculties; they usually have
heavy clinical responsibilities and educational obligations to students
and house staff, and they often have limited experience in clinical research.
Administrative positions in hospitals, clinics, and outpatient care services
are other career opportunities.
This report describes the factors that influenced
the development of a viable academic general internal medicine (GIM) program
over the past decade in a university-based comprehensive cancer center.
The steps taken to achieve goals in patient care, education, and research
are discussed.
General Internal Medicine at The University of Texas M.D.
Anderson Cancer Center
Because M.D. Anderson’s medical staff is composed of
oncology subspecialists whose expertise is often focused on one or two
specific malignancies, the institution’s leaders believed that patient
care would benefit from a cadre of experts in GIM who could bring advances
in other disciplines to the cancer patient. In addition, many new therapeutic
advances in medicine were developed in the late 1970s and early 1980s.
Since it was impossible for the medical oncologists to practice both oncology
and GIM and keep pace with advances in both specialties, the Division of
Medicine created a Section of GIM in the Department of Medical Specialties
in 1986. Initially, the Section functioned solely in patient care, but
it now provides education and research. The faculty of the Section currently
includes five full-time clinicians, an epidemiologist, a decision scientist,
and a health policy researcher.
Patient Care
The primary obligation of the Section of GIM is patient
care. The patient care areas include a GIM Consultation Service, a Medical
Specialties Inpatient Service, and staffing of the Ambulatory Treatment
Center (Fig 1).
The Consultation Service was formed initially to
assist the surgeons at the institution in the management of medical problems
of their patients perioperatively. Many patients who need aggressive surgical
procedures are elderly and have a multitude of underlying medical problems
that span numerous medical specialty areas. Several of the surgeons prefer
that one physician evaluate and coordinate their patients perioperatively.
The majority of consultations requested are for preoperative
risk assessment, mostly in the outpatient setting. The surgical clinics
schedule appointments with the general internist at the earliest convenience
for the patient, allowing time prior to the designated surgical date for
any necessary preoperative testing. The generalist and the surgeon discuss
each patient’s preoperative risk assessment. If surgery poses exceptionally
high risks for the patient, involvement of other medical specialties such
as cardiology and pulmonary medicine may be necessary to clearly define
and minimize all risks.
Some patients receive outpatient treatment (chemotherapy,
radiotherapy, or both) and have chronic medical problems that may be exacerbated
by treatment. Other patients may travel to our center from their hometowns
and thus are away from their regular physicians, and some patients have
not been under the care of a physician. During treatment, patients may
require close monitoring of their medical problems in the GIM clinic. When
treatment is completed, such patients are referred back to their own internists
or primary care physicians in the community.
The GIM Consultation Service provides a constant
educational stimulus for GIM faculty and house staff. The potential for
exciting consultations and diagnostic workups and the opportunity for clinical
research are unlimited. Our patient population presents with problems that
are distinct from those most other internists may see in their practices.
These patients have life-threatening diseases that often need urgent surgical
intervention if an optimistic prognosis is to be realized. In evaluating
perioperative risks, the prognosis of the cancer and a patient’s nononcologic
comorbid state weigh heavily in a physician’s decision making. Difficulty
in determining an accurate cardiovascular risk assessment in geriatric
cancer patients is due in part to the lack of data for this population.
With the experience obtained and information collected regarding these
patients during the last decade, we hope to contribute new insights in
assembling risk.
Other interesting medical problems are encountered
more often in cancer patients than in the general population. For example,
hypothyroidism secondary to prior radiation therapy to the head and neck
is often clinically undetected, and panhypopituitarism and hypo-adrenalism
occur surprisingly frequently.
Approximately 70 new consultations (an encounter
with a patient who has not been evaluated by a member of the section during
the prior three years) are scheduled with the Consultation Service per
month. An internal medicine resident is assigned to the service each month
and assists in evaluating and following the inpatient service. Common perioperative
problems encountered include atrial arrhythmias, pneumonia, hypertension,
hyperglycemia, deep venous thrombosis, and pulmonary embolism.
The annual consultation activity of the GIM Section
from its inception in May 1986 through 1996 is depicted in Fig 2. Activity
peaked in 1991 with 1,265 new consultations. The decrease in activity during
the last four years can be attributed to policy changes relating to indigent
care and managed care. Many of the patients previously evaluated preoperatively
with an indigent status are now being initially treated by the county’s
health care system with the aid of our center. A partnership was formed
to provide oncology expertise to the county by opening a county oncology
clinic staffed by an oncologist from our center. Many of the indigent patients
previously evaluated at our hospital and seen by the GIM Consultation Service
were from the departments of Head and Neck Surgery and Gynecology. Also,
during the last 18 to 24 months, many patients have been required to return
to the primary care physician designated by their insurer for preoperative
risk assessment and diagnostic workup.
Each internist in the section has one half day per
week allotted for individual medicine panels. The patients who are followed
in the clinic are those with oncologic disease and other medical problems
that may need ongoing attention.
A Medical Specialties Inpatient Service, another
area of patient care provided by GIM faculty, was established three years
ago to care for patients who require inpatient management of medical problems
not directly related to their oncologic diagnoses. Most of these patients
are cured of their disease or have stable disease with no recent cancer
treatment.
The Ambulatory Treatment Center (ATC), the third
patient care responsibility of the Section of GIM, is divided into four
components: the Emergency Center, the Bed Unit, the Chair Unit, and ATC-Greenpark.
The Emergency Center (EC) is an acute-care area with
22 rooms. The facility is open 24 hours per day, seven days per week, and
is always staffed by physicians. Annual activity in the EC is shown in
Fig 3. Patients seen in the EC are from the medical, surgical, and radiotherapy
departments and have acute problems requiring immediate attention. All
patients are evaluated by the EC physicians (unless the primary physician
wishes to evaluate the patient), and a decision on appropriate care is
made. The attending physician is contacted, and appropriate management
is discussed and determined. The most common complaints evaluated among
the EC patients are fever, uncontrolled pain, nausea and vomiting, and
dyspnea. Patients evaluated in the EC present more frequently with classic
oncologic emergencies than do patients seen in community emergency centers;
however, patients with cancer also present with angina secondary to ischemic
heart disease and exacerbation of chronic obstructive pulmonary disease.
The EC is equipped with a six-bed Medical Observation Unit, which allows
patients to avoid inpatient admission for problems such as dehydration,
nausea and vomiting, observation after procedures, and pain control. A
patient may remain in the Observation Unit for up to 24 hours, at which
time the patient is either discharged or admitted to an inpatient bed.
The Bed Unit, Chair Unit, and ATC-Greenpark (an off-site
facility) are designed for the administration of chemotherapy, blood products,
antibiotics, antifungals, monoclonal antibodies, and fluids. The general
internist assigned to these units visits patients and is available to evaluate
problems as they arise. Fig 4 demonstrates the activity of these three
areas. The Bed Unit and Chair Unit are open 16 hours each day, and ATC-Greenpark
operates weekdays from 7:00 AM to 6:30 PM. All administrations are scheduled
by appointment. The Bed Unit contains 25 rooms, the Chair Unit has 25 rooms
with recliners, and the ATC-Greenpark unit has 11 beds and seven chairs.
The Chair Unit accommodates administrations of less than four hours.
Education
House staff and medical students from the University
of Texas Medical School at Houston and other institutions are the main
focus of our educational endeavors. House staff are assigned to the ATC
and the Consultation Service. An intern is assigned to the ATC on a monthly
basis to evaluate patients admitted to the EC during the rotation. The
interns are taught to evaluate medical problems that are specific to the
population of patients seen at a cancer institution, including neutropenic
fever, intractable nausea and vomiting, pain, and electrolyte imbalances.
They also are allowed to perform procedures necessary for the evaluation
and treatment of patients (eg, Ommaya tap, lumbar puncture, thoracentesis,
and paracentesis) with faculty supervision.
A medical resident is assigned to the Consultation
Service and the Inpatient Medical Specialty Service on a monthly basis.
The resident not only evaluates the new inpatient consultations requested,
but also evaluates and writes daily notes on established consult and medical
specialty patients. The attending physician accompanies the resident on
daily rounds, and selected topics are discussed during rounds.
Medical students also rotate into the Section of
GIM. The rotation through the ATC is a four-week elective for senior medical
students who function as acting interns during this period. Also, several
of the GIM faculty serve as preceptors for sophomore medical students during
their course, "Introduction to Clinical Medicine." The GIM staff also participate
in the Summer Research Program for college and high school students interested
in a medical career.
The house staff and students are exposed to the latest
innovations in ambulatory care medicine. The technological breakthroughs
in pump delivery of drugs and the concept of outpatient care have allowed
our institution to become one of the first to excel in ambulatory care
medicine. House staff and students gain an understanding of the significance
of clinical research and often have opportunities to participate actively.
In this setting, house staff and students develop communication skills
that enable them to discuss issues such as death, dying, and supportive
care with patients and their families.
Education is also provided to other physician and
advanced clinical practitioner groups. Several of the physicians in the
section educate both physicians and laypersons in the community on numerous
topics relating to the care of patients with cancer. Lecture topics include
breast cancer screening, cancer risks, and oncologic emergencies.
Research
The research program in the Section of GIM has flourished
during the last decade. The program is integrated with the vital role of
the ATC in the M.D. Anderson system. The main objective of the research
efforts of the section is to develop novel and innovative research in supportive
cancer care and outcomes in cancer care. We have been studying ways to
improve the efficiency of cancer care by shifting traditional inpatient
treatment plans to outpatient programs.
We recently conducted a retrospective analysis of
111 elderly patients who had a head and neck operation between May 1986
and October 1990, as well as a preoperative evaluation by a staff physician
in the Section of GIM. The median age of patients was 84 years (range =
80 to 94 years). The Goldman Cardiovascular Risk Assessment Scores were
class I, 88 (79%), class II, 22 (20%), and class III, 1 (1%). Significant
factors for postoperative complications in the first seven days by univariate
analysis were as follows: preoperative history of myocardial infarction/
angina or preoperative pulmonary function testing predicted postoperative
myocardial infarction/angina (P=0.0273 and 0.0335, respectively),
preoperative history of arrhythmia or preoperative echo-cardiogram with
ejection fraction <50% predicted postoperative congestive heart failure
(P=0.029 and 0.0256, respectively), preoperative pulmonary function
testing predicted postoperative exacerbations of chronic obstructive pulmonary
disease (P=0.0038), and anesthesia time of longer than three hours
predicted fever (P=0.009). These data suggest that some octogenarians
and nonagenarians with head and neck cancer may be at low risk, and some
may be at increased risk of surgical complications. Very elderly head and
neck cancer patients at low risk may not need intensive preoperative screening;
however, it may be possible to identify those at higher risk who would
benefit from intensive preoperative screening. Such screening might reduce
postoperative complications and deaths.3
We also have developed a recognition of our work
in outpatient treatment of low-risk febrile neutropenic patients with cancer.4-6
Our future plans include the development and refinement of risk models
that will be used to direct cost-effective treatment programs for acutely
ill patients with dyspnea, intermediate- and high-risk febrile neutropenic
episodes, deep venous thrombosis, thrombocytopenia, and other common symptoms
related to cancer and its treatment.
Conclusions
Although our section is part of a comprehensive cancer
center, we have discovered that there is a strong need for generalist physicians.
Patients have medical problems in addition to cancer that require the medical
expertise of the generalist; house staff and students caring for patients
with cancer have questions that require the educational expertise offered
by the generalist; and health care professionals want improved methods
in supportive care that require the research expertise of the generalist.
Creativity and imagination, insights into the emergence,
elevation, and future of health services research, and the increasing stature
of the primary care physician in the setting of managed care have all contributed
to the establishment and success of the Section of GIM at M.D. Anderson
Cancer Center. Our generalists bring a well-rounded perspective to the
issue of complete care for patients with cancer.
References
1. Schwartz MD, Linzer M, Babbott D, et al. Medical student interest
in internal medicine: initial report of the Society of General Internal
Medicine Interest Group Survey on Factors Influencing Career Choice in
Internal Medicine. Ann Intern Med. 1991;114:6-15.
2. Linzer M, Slavin T, Mutha S, et al. Admission, recruitment, and retention:
finding and keeping the generalist-oriented student. SGIM Task Force on
Career Choice in Primary Care and Internal Medicine. J Gen Intern Med.
1994;9:14-23.
3. Escalante C, Elting L, Martin C, et al. Resource utilization and
surgical outcomes in elderly cancer patients. J Gen Intern Med.
1994;9(4 suppl 2):42.
4. Rubenstein EB, Rolston K, Benjamin RS, et al. Outpatient treatment
of febrile episodes in low risk neutropenic patients with cancer. Cancer.
1993;1:3640-3646.
5. Rubenstein EB, Rolston K. Outpatient management of febrile episodes
in neutropenic cancer patients. Support Care Cancer. 1994;2:369-373.
6. Escalante C, Rubenstein EB, Rolston K. Outpatient antibiotic therapy
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