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The American Journal of Managed Care November 2016
Referrals and the PCMH: How Well Do We Know Our Neighborhood?
Andrew Schreiner, MD; Patrick Mauldin, PhD, Jingwen Zhang, MS; Justin Marsden, BS; and William Moran, MD, MS
Does Medicare Advantage Enrollment Affect Home Healthcare Use?
Daniel A. Waxman, MD, PhD; Lillian Min, MD, MSHS; Claude M. Setodji, PhD; Mark Hanson, PhD; Neil S. Wenger, MD, MPH; and David A. Ganz, MD, PhD
A New Chapter in Health Reform
Michael E. Chernew, PhD, and A. Mark Fendrick, MD
Prescribers' Perceptions of Medication Discontinuation: Survey Instrument Development and Validation
Amy Linsky, MD, MSc; Steven R. Simon, MD, MPH; Kelly Stolzmann, MS; Barbara G. Bokhour, PhD; and Mark Meterko, PhD
Enhancing Patient and Family Engagement Through Meaningful Use Stage 3: Opportunities and Barriers to Implementation
Jaclyn Rappaport, MPP, MBA; Sara Galantowicz, MPH; Andrea Hassol, MSPH; Anisha Illa, BS; Sid Thornton, PhD; Shan He, PhD; Jean Adams, RN, ACIO; and Charlie Sawyer, MD, FACP
Integrated Care Organizations: Medicare Financing for Care at Home
Karen Davis, PhD; Amber Willink, PhD; and Cathy Schoen, MS
Reconsidering the Economic Value of Multiple Sclerosis Therapies
Tiffany Shih, PhD; Craig Wakeford, MA; Dennis Meletiche, PharmD; Jesse Sussell, PhD; Adrienne Chung, PhD; Yanmei Liu, MS; Jin Joo Shim, MS; and Darius Lakdawalla, PhD
Health Systems Tackling Social Determinants of Health: Promises, Pitfalls, and Opportunities of Current Policies
Krisda H. Chaiyachati, MD, MPH; David T. Grande, MD, MPA; and Jaya Aysola, MD, DTMH, MPH
Maternal Mental Health and Infant Mortality for Healthy-Weight Infants
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The Role of Internal Medicine Subspecialists in Patient Care Management
Jonathan L. Vandergrift, MS; Bradley M. Gray, PhD; James D. Reschovsky, PhD; Eric S. Holmboe, MD; and Rebecca S. Lipner, PhD

The Role of Internal Medicine Subspecialists in Patient Care Management

Jonathan L. Vandergrift, MS; Bradley M. Gray, PhD; James D. Reschovsky, PhD; Eric S. Holmboe, MD; and Rebecca S. Lipner, PhD
Most internal medicine subspecialists report the majority of their clinical time is spent in principal care or longitudinal consultative care patient management roles.

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


Data 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]). 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).


Average 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).

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