The Role of Internal Medicine Subspecialists in Patient Care Management

ABSTRACT

Objectives: To understand the clinical roles in which internal medicine (IM) subspecialists engage, especially those involving ongoing patient management.

Study Design: Measures of physician clinical roles were based on survey responses collected from 8020 mid-career IM subspecialists who registered for the American Board of Internal Medicine maintenance of certification program (86% registration/response rate) between 2009 and 2013.

Methods: Each subspecialist reported their percentage of clinical time in 5 clinical roles: primary, principal, longitudinal consultative, medical consultative, and procedural care. We characterized an IM subspecialist’s clinical role focus as those roles that composed a majority of their clinical time.

Results: Most IM subspecialists reported spending a majority of their time performing 1 (65%) or 2 (31%) clinical roles. Most (54%) reported a clinical role focused on ongoing patient care management roles, including principal care (eg, total responsibility for a specific condition, 23%), longitudinal consultative care (eg, shared care, 21%); or a mixed clinical role focus composed of both principal and longitudinal consultative care (8%). We also found that physicians focused on ongoing patient care management roles represent a significant percentage of physicians within most IM subspecialties (ranging from 19% to 88% across subspecialties).

Conclusions: A subspecialist’s clinical role focus is an important practice characteristic, and many subspecialists perceive themselves as playing a significant role in care management. These findings suggest there are opportunities to incorporate subspecialists into newer payment and care delivery reforms; they also bring to light reasons that training and certification programs should consider the different clinical role foci subspecialists adopt.

Am J Manag Care. 2016;22(11):e375-e381

Take-Away Points

Internal medicine subspecialists’ predominant clinical role is an important practice characteristic, and most subspecialists play a significant role in ongoing patient management:

• Many subspecialists report a clinical role focused on either principal care or longitudinal consultative care.
• These data suggest there are opportunities to incorporate subspecialists into payment and care delivery reforms.
• Physician training and certification programs should consider the clinical roles in which subspecialists engage when designing their programs.

Understanding the clinical roles that internal medicine (IM) subspecialists play is critically important in terms of both how we train and certify subspecialists, as well as how they are integrated into new models of care.^1-4 In general, a subspecialist’s clinical roles can be divided into those that include some degree of ongoing patient management responsibility versus providing consultative services on behalf of the managing physician.¹ The subspecialist's consultative roles are either cognitive (eg, providing diagnostic or management advice) or procedural (eg, evaluation for and/or performing a procedure on behalf of the managing physician) in nature.¹ The subspecialist’s patient management clinical roles can include operating as their patient’s primary care provider or principal care provider, or in a longitudinal consultative (eg, shared care) role. The primary care provider role includes assuming responsibility for accessibility, continuity, coordination, and comprehensive care for all patient concerns.⁵ The principal care provider role includes assuming responsibility for the ongoing management of a patient’s specific condition inside the domain of their specialty (eg, a rheumatologist managing care for a patient with lupus).^1,6-9 This is differentiated from a longitudinal consultative care role, wherein a subspecialist shares responsibility for managing a patient’s condition with the patient’s primary care provider (eg, a primary care physician and a cardiologist dividing and/or sharing cardiac care responsibilities for a patient with heart failure).¹

Although the consultative roles for subspecialists are well recognized, there is evidence suggesting that subspecialists commonly deliver ongoing routine care.^10-13 However, the specific patient management clinical roles in which they engage while providing this care is not well understood, and many data collected on the subject are more than a decade old. Given the increasing emphasis placed on improving care quality by better integrating and coordinating care across the multitude of providers with whom each patient comes into contact, it is important that we better understand the role, or roles, in which the subspecialist is engaged when providing this care.^2,14,15

To get a better understanding of the frequency with which IM subspecialists engage in these different clinical roles, we examined recent clinical activity reports by mid-career internists who subspecialized after their general internal medicine training. We also explored whether subspecialists vary the clinical roles in which they engage or adopt a singular focused role, and examined the degree to which physicians within a subspecialty adopt similar clinical roles. Notably, IM subspecialists represent about 15% of all physicians (and about 25% of nongeneralists) board certified over the past decade by the American Board of Medical Specialties.^16,17

METHODSData Source

We used data drawn from a survey completed during the enrollment process, and then updated every 18 months or more, for the 10-year Maintenance of Certification (MOC) program of the American Board of Internal Medicine (ABIM). This survey was initially developed by ABIM staff members to inform MOC policies and programs. This development team consisted of physician and nonphysician staff members, and the questions were tested with non-ABIM physicians to ensure clarity and consistency in their interpretation. We used data from subspecialists initially certified between 2000 and 2003, 86% of whom subsequently registered for MOC and completed the survey between 2010 and 2013 (14% nonresponse rate). After additional exclusions (detailed in Figure 1), our final sample included 8020 clinically active IM subspecialists (90% of professional time in patient care) (see eAppendix Table A [eAppendices available at www.ajmc.com]). Although the data used were collected by the ABIM, the design and conduct of the study; management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication, were all conducted by the authors independently of the ABIM. Physicians who enroll in an ABIM certification program enter into a business associates agreement that permits the ABIM use of their de-identified data at an aggregate level for research purposes.¹⁸ All data were de-identified prior to analysis.

Patient Management Clinical Roles

The survey included a question about time spent in different clinical roles (eAppendix [section 1]). Specifically, we examined the percentage of clinical time that respondents reported engaging in the following roles: 1) primary care, 2) principal care, 3) longitudinal consultative care, 4) medical consultative care, and 5) interventional or diagnostic procedural care. Clinical time delivering hospital or intensive care unit care was excluded.

Among these 5 roles, we classified 3 (primary, principal or longitudinal consultative care) as patient management roles because each involves the physician being continually responsible for some aspect of their patient’s care over time. This is distinct from medical consultative or procedural care roles, in which the physician is providing care (eg, evaluations and/or procedures) on behalf of the referring physician, who remains responsible for ongoing patient management.¹

The primary distinction between the 3 patient management roles is the scope of care for which the subspecialist is responsible. For example, the primary care provider role is one in which a physician assumes responsibility for all patient needs and generally serves as the medical home and first contact for new problems. In contrast, principal care is what occurs when a patient has 1 dominant medical condition that is chronic and is cared for almost exclusively by the subspecialist. This patient would also likely have a primary care physician who would see them for preventive care and acute problems unrelated to the major (ie, principal) condition. For example, a patient with severe lupus might receive principal care from a rheumatologist regarding medication and monitoring of their condition. Longitudinal medical consultative care is distinct from principal care because the patient may continue to see the subspecialist for select components of their care, but the primary care physician (or other healthcare provider) shares in the responsibility for caring for the patient’s primary condition. For example, a patient with diabetes may see their primary care physicians for some of their diabetes care (eg, routine glycated hemoglobin monitoring) and visit their endocrinologist only for certain aspects of care, (eg, medication adjustments).

Empirical Methods

We examined IM subspecialists’ engagement in clinical roles in 2 ways. First, we examined the average percentage of time physicians were engaged in the 5 different clinical roles. However, we observed a large degree of heterogeneity in mean time spent in different roles between physicians within a subspecialty because most physicians (96%) reported spending a majority of their clinical time in only 1 or 2 clinical roles.

To characterize this variation in clinical role foci across physicians, we also examined how frequently subspecialists reported spending a majority of their clinical time in 1 or 2 of the different clinical roles (which we refer to as their clinical role focus). In particular, when subspecialists reported a majority of their time was spent in 1 clinical role, we classified them as having a singular clinical role focus (eg, reporting 70% of time in principal care becomes having a principal care focus). For subspecialists for whom a single role did not compose a majority of their time, we classified them as having a mixed clinical role focus if the sum of their 2 largest clinical roles composed a majority of their time (eg, 40% procedural and 30% medical consultative care becomes procedural plus medical consultative care focused). We also grouped subspecialties as procedural or nonprocedural (eAppendix [section 2]).^19,20 All analyses were conducted using SAS version 9.3 (SAS Institute, Cary, North Carolina).

RESULTSAverage Percentage of Time in Different Clinical Roles

Overall, IM subspecialists reported 64% (standard deviation [SD] = 31) of their clinical time on average to be in clinical roles that involve patient management, mostly in principal care (mean = 29%) or longitudinal consultative care (mean = 30%; see eAppendix Tables B and C for median and mean clinical time by subspecialty). Physicians with nonprocedural subspecialties reported more time in patient management roles (mean = 79%; SD = 27%) than physicians with procedural subspecialties (mean = 51%; SD = 29%). That said, the time in clinical roles varied considerably among individual physicians within a subspecialty as indicated by the coefficient of variation often exceeding 100% (eAppendix Table C). This suggests that viewing measures of central tendency for these subspecialty groups, such as the mean or median time in the different clinical roles, may mask the typical clinical activity of many of these physicians.

Number of Subspecialists Grouped by Clinical Role Focus

Applying our measure that groups physicians by their clinical role focus, we observed a divergence of the clinical role focus among physicians within most subspecialties. This is somewhat analogous to the clinical role focus difference between general internists who practice as primary care physicians versus hospitalists. Overall, we found that 65% of subspecialists reported a majority of their time in a single clinical role and 31% in a mixed clinical role composed of 2 roles. A subspecialist’s clinical role focus composed 76% (SD = 14.6) of their clinical time on average (eAppendix Table D).

Most subspecialists (54%) reported a singular or mixed clinical focus composed of only ongoing patient care management roles (ranging from 88% of medical oncologists to 19% of physicians with tertiary cardiovascular disease certification). Mostly, this consisted of principal (23%) or longitudinal consultative care (21%) focused roles with few reporting a primary care clinical role focus (2%) (Figure 2). Another 18% reported a mixed clinical role focus in which only 1 of the 2 clinical roles included ongoing patient care management and the other was either procedural care or medical consultative care. In contrast, 23% of subspecialists reported a singular or mixed clinical role focus composed of only roles that do not involve patient care management (ie, procedural and/or medical consultative care).

We observed a large variation in clinical role focused practices both across and within subspecialties (Tables 1 and 2; eAppendix Table E). For example, 68% of subspecialists certified in tertiary cardiovascular disease (ie, certification in cardiovascular disease plus interventional cardiology or clinical cardiac electrophysiology) reported a clinical role focus that included procedural care. However, even among this procedural subspecialty, 19% of these physicians reported a majority of their time was spent in principal and/or longitudinal consultative care. For cardiologists without a tertiary certification, only 15% reported a clinical role focus that included procedural care but 53% reported a clinical role focus composed of principal care and/or longitudinal consultative care roles.

Demographic and Practice Characteristics

The vast majority of subspecialists included in the sample were male (75%) but were more evenly split between US (56%) and international medical graduates (44%) (Table 3). Most physicians had been in practice about 9 years (mean = 9.2; SD = 0.9) past fellowship, and they worked in private practices or practices owned by hospitals or health maintenance organizations (HMOs) (70%) that were small (2-10 physicians, 43%) or medium in size (11-50 physicians, 23%). The sample was geographically diverse, though most subspecialists practiced in in large central, fringe, or medium metropolitan settings (86%) (see eAppendix Tables F-H for clinical role data by demographic and practice characteristics).

DISCUSSION

Our key finding is that most IM subspecialists reported a clinical role focus composed of ongoing patient management roles (eg, primary care, principal care, or longitudinal consultation). In addition, we observed that many physicians within each subspecialty reported that they were involved in ongoing patient care management. Even among traditionally procedural subspecialties, such as gastroenterology or tertiary cardiovascular disease, a sizable proportion of physicians reported a clinical role focus composed of ongoing patient care management roles.

In aggregate, these data are consistent with prior research that found subspecialists to be significantly involved in delivering ongoing routine care.^10-12 For example, Valderas and colleagues¹² noted that about half of visits to medical specialists were for routine follow-up with established patients without referral. Our analyses suggest that the majority of this care appears to be provided by subspecialists operating in either a principal care or longitudinal consultative role, and that it is uncommon for subspecialists to adopt a primary care clinical role.

That we observed many IM subspecialists playing a significant role in managing their patients’ conditions raises important questions about how subspecialists fit into our evolving healthcare system. One concern might be that having a patient’s ongoing patient care responsibilities divided among physicians can have a negative impact on quality and efficiency if care is not carefully coordinated.^21,22 For example, consider a patient with diabetes who receives her “diabetes” care from her endocrinologist acting as her principal care physician, but also receives care from a general internist acting as her primary care physician. If the endocrinologist and general internist lack formal agreements about sharing responsibilities for care, then the patient is likely to experience gaps in care, such as follow-up care after hospitalization, or uncoordinated or delayed care because of confusion over the appropriate contact for an acute event. That said, when care is well coordinated, evidence suggests that co-management involving both a generalist and specialist can lead to better outcomes for patients with chronic conditions than having care managed by either type of physician alone.^23,24

Our findings also highlight the opportunity for incorporating subspecialists who report being responsible for their patients’ ongoing care into new alternative payment and delivery models. In particular, incorporating these physicians into the accountable care organization (ACO) framework will be important to ensuring that their incentives are aligned with those of their patients’ primary care physicians. For example, if an endocrinologist is providing longitudinal care for a patient with diabetes as part of the care team, but is excluded from any potential shared savings associated with good outcomes achieved by their patient, then they are likely to be less motivated to reduce waste and may even resent any financial benefits afforded other members of the care team.²⁵ This is especially pertinent given the recent passage of the Medicare Access and Children’s Health Insurance Program Reauthorization Act.²⁶ This legislation, in addition to repealing the sustainable growth rate formula, accelerates CMS’ efforts to transform physician payments from a system that rewards volume to one that rewards value. Providers who have substantial involvement in alternative payment or care models, such as patient-centered medical homes, ACOs, and bundled payment arrangements, will receive more generous Medicare fee increases than those who fail to meet criteria for substantial involvement. In response to concerns that alternative payment model options may be limited for some specialists, the law instructs CMS to develop alternative payment models that provide opportunities for specialists.

These findings also have implications for subspecialty credentialing, continuing education, and training. Credentialing organizations, such as the ABIM, should consider the different clinical roles that subspecialists play when designing their programs. For example, the observed heterogeneity of clinical role foci among physicians within a subspecialty supports recent changes to ABIM’s underlying certification policy.²⁷ This change removed the requirement that some subspecialists must maintain their underlying certification and instead allow maintenance of certification decisions to be decided by the individual physician based on their practice. For instance, physicians with a tertiary cardiovascular disease certification will no longer have to maintain their general cardiovascular disease certification. Many of these physicians reported a majority of their clinical time is focused on performing procedures (that may not require a general cardiovascular disease certification). However, there is a sizable group that does spend most of their time providing ongoing care management; for them, maintaining their certification in general cardiovascular disease might be beneficial. For some subspecialty fellowship programs, these data suggest educational curricula should consider offering training in providing effective ongoing, collaborative, patient care management. For instance, programs could utilize IM subspecialty milestones or adapt referral guidelines to design curricular activities tailored to the needs of the practice setting and clinical role focus the fellow might assume after completing training.^28-30

Limitations

Our methods for measuring the percentage of time in primary care activities have limitations. Data on clinical activity are self-reported and therefore subject to recall bias. However, the results observed here in aggregate are somewhat consistent with data reported previously.^12,13 For example, Edwards et al¹³ reported that 10% of patient visits to medical specialists in 2010 were reported to be primary care visits (vs the 5% of mean patient care time we observed). Furthermore, the role(s) to which a physician attributes most of their clinical time (ie, their clinical role focus) likely reflects the type of care a physician engages in most and is less subject to misclassification. Considering this, additional research is needed to quantify how divergent clinical practice is among physicians reporting different clinical role foci. This is especially true for the principal and longitudinal consultative care clinical roles, in which the discriminating characteristic is the degree to which the subspecialist adopts responsibility for ongoing management or shares it with another provider, such as the patient’s primary care physician.

These data also reflect repeated cross-sections of different IM subspecialists 10 years into their practice who enrolled in MOC, and so they may not generalize to younger or older subspecialists or to physicians who do not participate in MOC. Yet, subspecialists at mid-career are an important group, as they have more established practices than less experienced physicians and are likely to have a longer tenure in the profession than older physicians; also, most of these physicians do participate in MOC (86%). Furthermore, our results do not generalize to non-IM subspecialists. However, IM subspecialists are an important group given that they compose about a quarter of all nongeneralist physicians (ie, excluding general internists, family medicine physicians, or pediatricians).^16,17 Lastly, these data generally represent physicians who mostly provide patient care as part of small to medium community practices in medium to large metropolitan areas.

CONCLUSIONS

We observed that many subspecialists perceive themselves as spending a significant amount of clinical time in care management, either providing principal care or operating in a longitudinal consultative care role. In addition, the clinical role focus of a subspecialist’s practice, defined as the role(s) in which they engage most frequently, appears to vary among physicians within a subspecialty. These findings suggest that there are opportunities to incorporate subspecialists into newer payment and care delivery reforms, which may help avoid potential negative consequences, such as uncoordinated or fragmented care, of having subspecialists involved in patient care management. In addition, internal medicine subspecialty training and certification programs should work to ensure that physicians have the communication and coordination skills necessary to provide high-quality care as key members of a broader patient care management team, one that potentially includes their patient’s primary care provider as well as other specialists.

Acknowledgments

These data were, in part, previously presented June 8, 2014, at the Academy Health Annual Research Meeting in San Diego, California.

Author Affiliations: American Board of Internal Medicine (JLV, BMG, RSL), Philadelphia, PA; Mathematica Policy Research (JDR), Washington, DC; and Accreditation Council for Graduate Medical Education (ESH), Chicago, IL.

Source of Funding: Financial support and material support were provided by the American Board of Internal Medicine. Data used in the current study were collected by the American Board of Internal Medicine.

Author Disclosures: Mr Vandergrift and Dr Gray are employees of the American Board of Internal Medicine. Dr Reschovsky is an employee of Mathematica Policy Research and paid consultant to the American Board of Internal Medicine. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JLV, BMG, RSL); acquisition of data (RSL); analysis and interpretation of data (JLV, BMG, JDR, ESH, RSL); drafting of the manuscript (JLV, BMG, JDR, ESH, RSL); critical revision of the manuscript for important intellectual content (JLV, BMG, JDR, ESH, RSL); statistical analysis (JLV, BMG, RSL); obtaining funding (RSL); and supervision (RSL).

Address Correspondence to: Jonathan L. Vandergrift, MS, American Board of Internal Medicine, 510 Walnut St, Ste 1700, Philadelphia, PA 19106-3699. E-mail: Jvandergrift78@gmail.com.

REFERENCES

1. Forrest CB. A typology of specialists’ clinical roles. Arch Intern Med. 2009;169(11):1062-1068. doi: 10.1001/archinternmed.2009.114.

2. Starfield B. Primary care, specialist care, and chronic care: can they interlock? Chest. 2010;137(1):8-10. doi: 10.1378/chest.09-1441.

3. Fisher ES. Building a medical neighborhood for the medical home. N Engl J Med. 2008;359(12):1202-1205. doi: 10.1056/NEJMp0806233.

4. Walker J, McKethan A. Achieving accountable care—“it’s not about the bike.” N Engl J Med. 2012;366(2):e4. doi: 10.1056/NEJMp1112293.

5. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502.

6. Aiken LH, Lewis CE, Craig J, Mendenhall RC, Blendon RJ, Rogers DE. The contribution of specialists to the delivery of primary care. N Engl J Med. 1979;300(24):1363-1370.

7. Kirschner N, Greenlee MC. The patient-centered medical home neighbor: the interface of the patient-centered medical home with specialty/subspecialty practices. American College of Physicians website. https://www.acponline.org/system/files/documents/advocacy/current_policy_papers/assets/pcmh_neighbors.pdf. Published 2010. Accessed October 12, 2016.

8. Donaldson MS, Yordy KD, Lohr KN, Vanselow NA. Primary Care: America’s Health in a New Era. Washington, DC: National Academies Press; 1996.

9. Langdon LO, Toskes PP, Kimball HR. Future roles and training of internal medicine subspecialists. American Board of Internal Medicine Task Force on Subspecialty Internal Medicine. Ann Intern Med. 1996;124(7):686-691.

10. Fryer GE Jr, Consoli R, Miyoshi TJ, Dovey SM, Phillips RL Jr, Green LA. Specialist physicians providing primary care services in Colorado. J Am Board Fam Pract. 2004;17(2):81-90.

11. Rosenblatt RA, Hart LG, Baldwin LM, Chan L, Schneeweiss R. The generalist role of specialty physicians: is there a hidden system of primary care? JAMA. 1998;279(17):1364-1370.

12. Valderas JM, Starfield B, Forrest CB, Sibbald B, Roland M. Ambulatory care provided by office-based specialists in the United States. Ann Fam Med. 2009;7(2):104-111.

13. Edwards ST, Mafi JN, Landon BE. Trends and quality of care in outpatient visits to generalist and specialist physicians delivering primary care in the United States, 1997-2010. J Gen Intern Med. 2014;29(6):947-955. doi: 10.1007/s11606-014-2808-y.

14. Sinsky CA. The patient-centered medical home neighbor: a primary care physician’s view. Ann Intern Med. 2011;154(1):61-62. doi: 10.7326/0003-4819-154-1-201101040-00010.

15. Chen LM, Ayanian JZ. Care continuity and care coordination: what counts? JAMA Intern Med. 2014;174(5):749-750.

16. Number of candidates certified annually by the American Board of Internal Medicine. American Board of Internal Medicine website. http://www.abim.org/~/media/ABIM%20Public/Files/pdf/statistics-data/candidates-certiified-annually.pdf. Accessed October 12, 2016.

17. 2013-2014: ABMS board certification report. American Board of Medical Specialties website. http://www.abms.org/media/84770/2013_2014_abmscertreport.pdf. Accessed October 12, 2016.

18. Privacy policy. American Board of Internal Medicine website. www.abim.org/privacy-policy.aspx. Published January 1, 2014. Accessed April 24, 2015.

19. Kaminetzky CP, Keitz SA, Kashner TM, et al. Training satisfaction for subspecialty fellows in internal medicine: findings from the Veterans Affairs (VA) Learners’ Perceptions Survey. BMC Med Educ. 2011;11:21. doi: 10.1186/1472-6920-11-21.

20. Langdon LO. Subspecialty internal medicine in the United States: in and outside the hospital. Schweiz Med Wochenschr. 1999;129(48):1870-1876.

21. Cebul RD, Rebitzer JB, Taylor LJ, Votruba ME. Organizational fragmentation and care quality in the U.S. healthcare system. J Econ Perspect. 2008;22(4):93-113.

22. O’Malley AS, Reschovsky JD. Referral and consultation communication between primary care and specialist physicians: finding common ground. Arch Intern Med. 2011;171(1):56-65. doi: 10.1001/archinternmed.2010.480.

23. Ayanian JZ, Landrum MB, Guadagnoli E, Gaccione P. Specialty of ambulatory care physicians and mortality among elderly patients after myocardial infarction. N Engl J Med. 2002;347(21):1678-1686.

24. Willison DJ, Soumerai SB, McLaughlin TJ, et al. Consultation between cardiologists and generalists in the management of acute myocardial infarction: implications for quality of care. Arch Intern Med. 1998;158(16):1778-1783.

25. Blumenthal DM, Song Z, Jena AB, Ferris T. Guidance for structuring team-based incentives in healthcare. Am J Manag Care. 2013;19(2):e64-e70.

26. H.R.2—Medicare Access and CHIP Reauthorization Act of 2015. Congress.gov website. https://www.congress.gov/bill/114th-congress/house-bill/2/text. Accessed October 12, 2016.

27. ABIM will discontinue requirement for maintaining underlying board certification. American Board of Internal Medicine website. https://www.abim.org/news/abim-will-discontinue-requirement-for-maintaining-underlying-board-certification.aspx. Published July 1, 2015. Accessed September 30, 2015.

28. Accreditation Council for Graduate Medical Education; American Board of Internal Medicine. The internal medicine subspecialty milestones project. Accreditation Council for Graduate Medical Education website. http://acgme.org/acgmeweb/Portals/0/PDFs/Milestones/InternalMedicineSubspecialtyMilestones.pdf. Published July 2015. Accessed October 12, 2016.

29. Chen AH, Yee HF Jr. Improving the primary care-specialty care interface: getting from here to there. Arch Intern Med. 2009;169(11):1024-1026. doi: 10.1001/archinternmed.2009.140.

30. Murray M. Reducing waits and delays in the referral process. Fam Pract Manag. 2002;9(3):39-42.

Download PDF: The Role of Internal Medicine Subspecialists in Patient Care Management