Sunday, July 09, 2006

Internal Medicine’s identity crisis

An introduction to the specialty of Internal Medicine from the University of Maryland School of Medicine website linked in my June 15 post on the subject has this description: (italics mine) “But the internist always remains the physician (or the diagnostician as internists were called in former times) whose special competence is solving difficult diagnostic problems and personally applying, or obtaining from a colleague, the best treatment available.” It also contains this statement: “Internists have always required special training to acquire their knowledge and skills and have continuously shown a particular interest in the scientific basis of clinical work.”

DB expanded on this view when he described what attracted him to Internal Medicine: (italics mine) “I am driven by both the intellectual challenge and the interpersonal relationships in medicine. I enjoy puzzle solving and relating to individual patients.” Also this: “Internal medicine deals with the most complex patients and most complex situations. Internists handle complex comprehensive care.”

Internal Medicine is thus distinguished by a unique emphasis on scientific underpinnings of medicine and the handling of complex problems. What is the popular notion of Internal Medicine? In search of something “official” I checked the American College of Physicians webpage and was disappointed. They characterize internists merely as "doctors for adults" and elaborate by listing what internists don’t do, such as deliver babies and treat kids. That’s it. For a description of a specialty this definition contains nothing special! The American College of Physicians has thus succeeded in defining Internal Medicine as nothing more than a subdivision of Family Practice, further contributing to Internal Medicine’s identity crisis.


james gaulte said...

I agree. With friends like the ACP, internists do not need any enemies.

Anonymous said...

Below I have copied the definition from the ACP website. The terms have always been confusing but I think this is an honest attempt to capture a complex and vital specialty whose members now do a variety of things.

Any suggestions for additions or corrections to the definition below?

Fred Ralston MD FACP
General Internal Medicine
Fayetteville, Tennessee
Regent, ACP

About Internal Medicine

Doctors of internal medicine focus on adult medicine and have had special study and training focusing on the prevention and treatment of adult diseases. At least three of their seven or more years of medical school and postgraduate training are dedicated to learning how to prevent, diagnose, and treat diseases that affect adults. Internists are sometimes referred to as the "doctor's doctor," because they are often called upon to act as consultants to other physicians to help solve puzzling diagnostic problems.

What's an "internist"?

Simply put, doctors of internal medicine are Doctors for Adults. But you may see them referred to by several terms, including "internists," "general internists" and "doctors of internal medicine." But don't mistake them with "interns," who are doctors in their first year of residency training. Although internists may act as primary care physicians, they are not "family physicians," "family practitioners," or "general practitioners," whose training is not solely concentrated on adults and may include surgery, obstetrics and pediatrics.

Caring for the whole patient

Internists are equipped to deal with whatever problem a patient brings -- no matter how common or rare, or how simple or complex. They are specially trained to solve puzzling diagnostic problems and can handle severe chronic illnesses and situations where several different illnesses may strike at the same time. They also bring to patients an understanding of wellness (disease prevention and the promotion of health), women's health, substance abuse, mental health, as well as effective treatment of common problems of the eyes, ears, skin, nervous system and reproductive organs.

Caring for you for Life

In today's complex medical environment, internists take pride in caring for their patients for life -- in the office or clinic, during hospitalization and intensive care, and in nursing homes. When other medical specialists, such as surgeons or obstetricians, are involved, they coordinate their patient's care and manage difficult medical problems associated with that care.

Internal medicine subspecialties

Internists can choose to focus their practice on general internal medicine, or may take additional training to "subspecialize" in one of 13 areas of internal medicine. Cardiologists, for example, are doctors of internal medicine who subspecialize in diseases of the heart. The training an internist receives to subspecialize in a particular medical area is both broad and deep. Subspecialty training (often called a "fellowship") usually requires an additional one to three years beyond the standard three year general internal medicine residency.

What does "internal medicine" mean?

The term "Internal Medicine" comes from the German term Innere Medizin, a discipline popularized in Germany in the late 1800s to describe physicians who combined the science of the laboratory with the care of patients. Many early 20th century American doctors studied medicine in Germany and brought this medical field to the United States. Thus, the name "internal medicine" was adopted. Like many words adopted from other languages, it unfortunately doesn't exactly fit an American meaning.

Download Brochure

Download the "What is a Doctor of Internal Medicine?" brochure containing the information on this page. (PDF format: Adobe Acrobat needed)

Robert W Donnell said...

Dr. Ralston,
Thank you for your reply. It's gratifying to see someone from ACP expressing concern.

First of all I would de-emphasize "doctors for adults." Although that needs to be included in order to delineate the limitations on the scope of practice it does little to distinguish IM as a specialty, so I would not give it top billing. The sentence "Simply put, doctors if internal medicine are Doctors for Adults" is just that---too simple in my view.

The part about the internist being the "doctor's doctor" as a consultant for complex problems is really the defining characteristic, not an ancillary characteristic and thus deserves greater emphasis.


Anonymous said...

I think that poor reimbursement for "E&M" services is what is actually destroying internal medicine. Internists are forced to see more patients and this interferes with their ability to manage complex issues. It is more economically efficient to "triage and refer" rather than to "diagnose and manage" given the current payment systems. Sad but true.

Robert W Donnell said...

I agree that poor reimbursement is destroying IM---but I think it may stem from a reimbursement system which fails to distinguish IM from FP, symptomatic of IM's loss of identity.

Anonymous said...

Heya RW,

1. I really enjoy your blog. Thanks!!

2. Here in Canuckistan, internists are the docs we (FPs) refer to when something is just weird, complicated, more specialized than FP but less specialized than an isolated system.

(Something doesn't fit into the boxes of endocrine, cardiology, rheumatology, etc.)

What the ACP calls a "doctor's doctor."

3. What does family practice have to do with under-remuneration for internists?


Anonymous said...

I would do my IM job feeling much more dignity if i could spend more time with a patient and recieve much more money for that, indeed internists are needed; we are cost efective, but i think that with the present scenario we'll be witnesing a progresive shortage of internist in USA and the entire world.