I think there are two different arguments here.
1.) We are in agreement that no body should treat something purely for their ego. With that being said, I think if a patient is presenting with new symptoms and you clearly diagnose said individual, you should be able to treat them with the first couple lines of therapy if you've done your homework, know what to watch for, know what blood tests they need to be monitored for, and any sequelae of that. Obviously this post is not about never sending anyone to a specialist - Medicine is a team sport - But just as the specialist is an expert, inevitably a smart person who's referred a patient to a specialist several times and picks up their patterns will know what they might do next and how you can predict their care patterns and therefore have the patient 100% fattened up before serving them all juicy for the specialist to dig in and know immediately "what's up". A good PCP can make the life of that specialist (and patient) way easier, but only if they exercise their ability to do so, and not get content just triaging and treating 5 things. But, that does require "exercising", you don't use it, you lose it.
I think there are clear guidelines when you should send a patient to a specialist. I think it's also more complicated than just watch for the common sequale and knowing what drug. A common disease such as osteoporosis can be really mismanaged to the point that we actually saw increased fracture rates because people didn't know enough about the second line agents they started prescribing as quazi first line agents. Same thing with seroquel being a fad until people needed to slam the hammer and tell people it was making old folk delirious and caused more trouble. I think there's plenty of room for a second opinion and extra management if it means the patient will have statistically better outcomes.
I mean there's really a lot that I'm not allowed to do. If a pt has HIV I could easily order all the labs for genotype testing and start them on a first line anti-retroviral. But I also don't see enough of these patients to be 100% sure I'm missing something big or some new guideline that came out in the I.D literature. So to the ID doctor they go.
2.) I think when people talk about FM they traditionally mean outpatient. With that being said, a FM doc who's done more inpatient and has worked several years as a hospitalist I have no doubt in my mind they are just as competent inpatient as an IM doctor. It's all about what the physician has trained and prepared themselves for, just as it might be a bit of a shock for an inpatient IM or FM doc to move outpatient after several years of inpatient work. It's good for FM to get this exposure inpatient because you need to know what will happen in the hospital and more importantly, what can land your patients in the hospital. In the hospital, you can have your way with anyone - They're yours. You want that specialist? They're there. You want that patient to get that med or take that test? They do it, with an aid/nurse personally bringing them directly to it. The outpatient animal is, yes, the patient with 3-4 chronic complaints that are difficult to manage needs to see 2 specialists. But...... due to any number of social determinants of medicine, there is a high likelihood that patient WILL NOT be able to follow up with said specialists. Whether it be financial, psychiatric, physical, whatever. So ultimately, if you're not prepared to do that for your patient, you're doing them a disservice, but you can only do that for them if you've been committed to learning and not just passing off anyone difficult.
Most FM docs can probably do either inpatient or outpatient. Same thing with IM. The difference is that IM's curriculum is loaded with more subspecialty rotations and ICU management. Most IM seniors will be managing a lot more critically ill patients and their volume and exposure with decompensated patients will influence their clinical decision making and triage. There are limits to what we can learn from our exposures.
I think that's fair. That being said, if my patient who has advanced cardiomyopathy or cirrhosis isn't going to their Cards or GI doctor. Then the most I can do is basic medical management. They need more than that and they'll either die on the way to getting it or get it in patient.
I think outpatient and inpatient are completely different animals. I think it's sad that PCPs no longer round on their patients in the hospital. I obviously understand why it's just not feasible with the complexities of todays world. But it's sad because this person who really should have an intimate relationship with the patient seeing them could probably save so much time and money by not re-inventing the wheel.
I think telemedicine is going to have the biggest impact on the life of a PCP. Imagine being able to "tele-consult" with such fluidity and ease. Put a go-pro on my head, watch me do this physical exam, ask the patient questions in real time, share-screen the patient chart, etc. etc. And this could definitely change the landscape as to how fast and efficient patients can get treated, but ultimately the PCP needs to stretch and workout their brain so they can be more efficient to rely less on specialists, but know they're always there when you need them. I think we are in agreement and this is more semantics, I think specialists might sometimes get this motherly instinct kick-in like when they have to watch their kid use a butcher knife for the first time. They have to trust, be always be ready to jump in or critique as needed, but eventually the PCP should be trusted and know what they are / are not good at.