Saturday, January 08, 2011

What is an internist anyway?

One time years ago, when it came out in conversation that I was a doctor, a lady asked what kind of a doctor I was. “An internist,” I said. “Are you learning a lot?” she asked. From that moment on I never told anyone I was an internist. My usual answer became “I am a specialist in internal medicine.” Clearly internal medicine struggles with its identity.

The other day DB did a little experiment. He asked readers to submit answers to the question “What is an internist?” He got eleven replies, mainly from internists, and nobody seemed to nail it.

In a follow up post he reflected on the difficulty we have in defining our specialty. He had this to say about what an internist is/does:

I like the comment about diagnostician, because in my experience that is the crux of the issue. Our job always involves diagnosing the patient, whether diagnosing a disease, the severity of disease, the response to medication (including unacceptable side effects), the patient's goals of therapy, or the social situation. Internists diagnosis and then appropriately treat adult patients. The location of our practice or the scope of our practice (generalist or subspecialist) does not change with that definition. Excellent internists order diagnostic tests (laboratory tests, observation over time, imaging studies or even referral to a subspecialist) in order to help the patient receive the most desirable outcome. That outcome depends on our diagnosis of the patient's desires.

True enough, but isn't that what every good doc does regardless of specialty? Does it explain the uniqueness of IM? Well, only if it means, at the substantial risk of sounding elitist, that internists are superior to other specialists in diagnosis and appropriate treatment! That may not bother our orthopedic colleagues (“I'm just a dumb bone cruncher”) but how would it sit with others? The true notion of IM is about expertise at a special level of complexity in diagnosis and treatment.

Sapira's Art and Science of Bedside Diagnosis, on page 7, defined it thus:

(1) (Obsolete) That nonsurgical medical specialty concerned with clinical diagnosis and scientific therapy. Previously a secondary-care consultant specialty, it underwent crisis by lysis in the late 1960s; (2) (contemporary) a biopolitical consortium of balkanized tertiary nonsurgical subspecialties, which, oxymoronically, claim it to be a primary care specialty.

Definition 1 gets close to the true notion of IM. It truly is a secondary-care consultant specialty. (Well, yes, it's devolved considerably form that state, but that's the original idea). This is not easy to define and requires elaboration. I attempted to do so in a Medscape Roundtable piece a couple of years ago. I reviewed the history of the specialty, hoping that would add clarity to the true notion of IM.

Rather than elaborate on what I said there, let me recount my own journey. I was profoundly influenced by my dad. He was an old fashioned GP in the suburban fringes of St. Louis. He had great admiration for internists. He had always wanted to be one, but when he started his IM training WW II got in the way. After the war he was ready to come home and hang out the shingle. Though a skilled diagnostician himself, he had a special regard for internists. He held them in awe. Whenever he had a really really tough case he called the internist.

When my mom developed a mysterious illness he called a colleague he considered one of St. Louis's finest internists. When she was finally diagnosed with Graves disease things didn't get any easier. The tests used to monitor thyroid treatment in those days (the BMR and PBI) were crude and required a great deal of clinical skill to use. During the difficult course of her illness there were many encounters with the internist. By the time she recovered I knew that an internist was a specialist.

Fast forward to medical school. Every department had its outstanding mentors, but clearly the master clinicians were in the department of Internal Medicine. The exemplar was Thomas Brittingham. His teaching rounds were awe inspiring. Brittingham didn't promote IM over other specialties but through his teaching I learned that an excellent internist was not only a medical detective, but also the one you called for severe illness and very difficult management situations.

Our professional organizations need to do a better job of defining and promoting the specialty. The American College of Physicians slogan “Doctors for Adults” is unfortunate because it defines Internal Medicine as Family Practice without Pediatrics. This view has led to a proposal, published in the Journal Academic Medicine, that IM and FP be merged. It would mean the dissolution of general IM as a specialty. It's little wonder so few trainees want to go into general IM anymore. Who in their right mind would sign up for a specialty that's slated for dissolution in the next decade?

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