Sunday, March 11, 2007

Misunderstanding Internal Medicine

I’ve done some thinking the last few days about readers’ reactions to my posts on Internal Medicine as a specialty. The common understanding of Internal Medicine differs a great deal from my own. Judging from comments I’ve read my view needs better explanation. First I would recommend DB’s postulates, which were posted late in the discussion and should go a long way toward answering many of the questions.

I was taken to task on the one hand for listing all the things Internal Medicine is not without addressing what it is, and on the other hand for claiming that Internal Medicine is everything Family Practice is, only better. One would think I was talking out of both sides of my mouth.

Emmy commented “OK, well you have told us what Internal Medicine doctors are not. Would you now tell us what they are? Because I'm kind of confused. You see, I go to an Internal Medicine doctor as my primary care physician, and if that's not her role then I can't see what else her practice would be described as.“ A broad range of adult problems comprises Internal Medicine. Internists do in fact practice primary care when it is defined as that care which is given by the first doctor the patient sees for a problem. But I agree with DB that the term has been hijacked by so many people with agendas that it has become meaningless. It’s not useful in defining Internal Medicine as a specialty. While Internal Medicine and Family Practice are overlapping circles in a Venn diagram there is a difference in focus and there are distinctions.

Internal Medicine and Family Practice are overlapping, though not identical, specialties. There are problems (and I’m not just referring to Ob/Gyn and Peds) in the realm of expertise of Family Practice for which internists are not particularly well trained and vice versa. As I once explained, Internal Medicine stresses the care of patients with multiple complex problems. As DB said in his postulates internists have more training in the care of severely ill patients. Internists are (or should be!) uniquely, more than other specialists, interested in the basic scientific underpinnings---the how and why---of both normal function and disease. (Note that the word “internal” is apt here).

This concept of multiple complex medical problems as a defining attribute of the Internal Medicine patient is evidently difficult for some, but Emmy of all people should understand. Just look at her profile. (Emmy, by all means, stick with your internist!).

Some medical students read my blog and commented over at the Student Doctor Network Forum. Their comments suggest that they too misunderstand what general IM is supposed to be:

I suppose if the public expects you to act like a family physician, it only makes sense to train as one.

…the people who don't go on to fellowships will have a hard time.

There is nothing that IM covers that there is not a specialty for (Intensive Care, Pulmonology, Cardiology... etc etc etc) so how can you call them a specialty.

Why? They can be hospitalists...

Wow. No wonder it’s difficult to get students to choose general Internal Medicine.


Vicki Small said...

Interesting post. We have been under the excellent care of a family physician for most of the past 10 years. During other long periods of my life, my primary physician (even before the term came to be) was an internist, also an excellent doctor. My concept, based on little knowledge, has been that a specialty in family medicine covers a wider range than internal medicine, and you have set me straight . . . although I'm still a little fuzzy. That's okay; as long as my doctor is knowledgeable and communicative (which includes a willingness to listen to the patient), I'm happy.

Anonymous said...

How can you expect medical students to like internal medicine? They never see it!

There is little is any clinic experience in medical school, and what little there is takes place in huge public hospital clinics that bear little resemblance to what doctors actually do in the community.

In the hospital, chest pain goes to the cards service, pneumonia to pulm, GI bleeding to GI and cancer to oncology. The medicine service is old people with urosepsis, loss of caregiver, and management of decubitus ulcers.

Until medical education can give a better view of what internal medicine is, few students are going to want this job.

Of course, internal medicine needs to decide this for itself first. Why don't other specialties have this problem?