Information, including real-time streaming data, is increasingly moving from patient to doctor in some common databases. Such systems enhance two-way communication and connectivity but likely decrease physical visits. As such systems move into community-oriented, primary care settings, general internists (and family physicians) may be the practitioners most attuned to what patients want: information and care management, as participants in the patient's and family's health care team.
Ideally, all Americans would have access not only to care but also to better information about what services accomplish and cost. By supporting excellence in medical practice, an ideal system would lead to good outcomes through shared information and well-designed structures. Physicians would be paid for everything they do, including nonoffice services (for example, phone and e-mail consultation).38
Payment would also be based on complexity and conceivably also on meaningful measures of quality of care. Point-of-service clinical information systems and decision aids based on published literature would be available to patients and families. A scenario with a view to the future can be viewed at http://www.sgim.org/futureofGIM.pdf
At its core, the domain of general internal medicine will remain primary and principal care of adults—either directly or as a member of a team. General internists will keep seeking and filling voids as they become evident, to meet patients’ rising expectations and demand for technical quality of care. Internal medicine will be dominated by common chronic diseases42,43
including heart disease, diabetes, arthritis, pulmonary diseases, neurodegenerative disorders, and general therapeutics, especially drug therapy. Competency in geriatrics will become increasingly important.44
Chronic and complex disease management and primary medical care—especially for preventive, patient-activating, behavior change, and adherence- and health-promoting services—will be increasingly evidence based. General internal medicine will move to a system of management designed to monitor and promote successful outcomes. Practitioners must be both comprehensive and efficient, monitoring outcomes of patients in their practice regularly and routinely.
Doctors will work in systems and thus must have mastery in systems thinking and development. Clinical skills will be valued and closely linked to communication skills. The internist's unique role will involve interpreting and applying the knowledge stream and managing information and knowledge as part of an ongoing personal and caring relationship with patients, as well as educating colleagues and team members.
Team members will change over time, but the internist, patient, and family will remain constant. Team members (e.g., cardiologists, other generalist physicians, nurses, case managers, physician extenders, and others) will review data online, usually asynchronously. General internal medicine specialists will be able to provide the majority of care that a particular patient with a chronic disease requires. To accomplish this, they must be trained to achieve and maintain expertise in problems commonly found in adult medicine (including those in the domain of other subspecialties) and able to coordinate care across a health care system.
At the same time, general internists will communicate closely with specialists who comanage patients with complex diseases. Instead of providing parallel, often uncoordinated services, all those involved in caring for a patient will seamlessly coordinate for optimal quality and efficiency.24,30,31
As experts in chronic illness management, general internists are well-suited to communicate effectively with specialists and to integrate their recommendations into an individual plan of care.
As demands rise for quality performance measures, general internists should become the quality-accountable physicians. This role will be challenging, given recent evidence that spending more on care does not boost access or quality,45,46
and subsequent pressures to reduce spending.47,48