Saturday, February 24, 2007

The Dinosaur on Internal Medicine, Family Practice and primary care

The recent discussions on Internal Medicine as a specialty must have pushed The Dinosaur’s buttons. Well, a dinosaur should be able to remember a time when everybody knew an internist was a specialist. The Dinosaur wants to corner me with questions like “Describe to me when, who and why I should refer to you?” and “Do you expect me to say something like this: ‘Well, Mrs. Smith, now that you have multiple complex diseases, I think you should be under the care of a specialist. I'd like you to go see an Internist. They won't provide your primary care [what exactly is that in this context? Immunizations?] but because they enjoy the complexity and diagnostic challenge, I think you will benefit from their style of training and deeper understanding of complex diseases.’ Huh?”

DB of Med Rants has given us a clear description of the concept of Internal Medicine. But Dinosaur’s questions mock DB’s conceptual description by trying to trap us into proposing an airtight, concrete categorization which he/she could shoot down with numerous counter examples and which would not be applicable to the real world where specialty boundaries, no matter what the specialty, are fuzzy. Who treats hypertension? FPs, internists, cardiologists and obstetricians, all of whom can do it well. Which specialties treat strokes? It depends on many factors including the resources available in the community and the comfort level of the individual physician, but it could be FP, IM or neurology. Who should manage ventilators in the ICU? Again, the answer is “it depends.”

I learned how Internal Medicine functions as a specialty from my former private practice in a multispecialty group which had a lot of family practitioners. Although patients didn’t walk through the door with labels that said “multiple complex problem patient” everybody knew who they were, at least after an encounter or two. The FP, who treated hypertension just fine, might send me the hypertensive with renal disease who was refractory to a three drug regimen. If my hypertension patient called in with an eye injury I would direct him to the FP, more than happy to see the patient, especially thankful that I had taken over the care of his pneumonia patient who, the previous day, developed ARDS and required transfer to the ICU. Everyone understood the difference between Internal Medicine and Family Practice, the result of which was an optimal collaboration for the benefit of patients.

The point of my ranting was never to define the scope if Internal Medicine, or any other specialty, in absolute terms. And though such absolutes would have little meaning in today’s clinical world the specialty of Internal Medicine has important distinctions.

I struggle to understand to what extent Dinosaur agrees with me, but the final paragraph of yesterday’s musing (whether Dino realizes it or not) agrees with me wholeheartedly: “Once you present yourself as willing to take care of anyone who walks in the door, you are by definition offering Primary Care, whatever you call yourself. If you see yourself as a specialist -- and want to be treated like one -- it's probably best to start by acting like one.” Indeed. Just what I’ve been saying, perhaps spoken better than I did! Too many internists, right in line with the American College of Physicians, have forsaken the identity of Internal Medicine by presenting themselves merely as doctors who are “willing to take care of anyone who walks in the door.” That’s a conceptual problem that needs fixing if we wish to avoid the dissolution of Internal Medicine.


#1 Dinosaur said...

I agree that I began my rant rather snarkily, and found myself mellowing as I went on. So yes, the final line was my real point.

The "button pushing" is when it sounds like you are trying to have your cake and eat it too, by somehow implying that although you're doing the same things I am you are somehow doing it "better." DB's more recent postulates go a long way toward clarifying things by offering Family Practice some of the respect that seemed missing previously.

I agree that the specialty aspect of IM is indeed clearer in the context of a multi-specialty group. I'm a lot more comfortable with the idea of a specialist willing to recognize that what I bring to the table is also of value, and not just a lesser version of what they do. And I believe I understand your pain, what with the pressures on you to do things that you don't consider within your scope of care.

So I guess what I agree with is that some of you are having significant difficulties with your specialty society, as they try to push you along a path with which you are not in agreement.

Join the club; the AAFP discussion boards are hotbeds of dissent and dissatisfaction.

R. W. Donnell said...

Thanks for the clarification, Dinosaur. FP and IM are in my view distinct specialties which overlap but by no means do exactly the same things, and neither does them "better" than the other. Collaboration is optimal when the distinctions between the specialties are understood. I would not have survived professionally without the FPs in my original medical group. They made it possible for me to be an internist in the true sense of the word.