American College of Physicians: Internal Medicine — Doctors for Adults ®

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Why internal medicine needs a collaborative curriculum

From the September 1996 ACP Observer, copyright 1996 by the American College of Physicians.

By Christine K. Cassel, FACP

The idea of a curriculum for internal medicine offers a great deal of promise at this moment in history, but it also presents considerable challenges.

The old Chinese proverb, "every challenge is also an opportunity," may offer some guidance. We tend to assume that challenge and opportunity are dichotomous, the opposite of one another. In the case of a curriculum for internal medicine, however, I believe that working through the many challenges that the process presents will help us realize opportunities and will benefit the profession. For this reason, the completion of the resource document from the Federated Council of Internal Medicine (FCIM) may be of truly historic significance for our discipline.

Internal medicine has undergone extraordinary growth in the past few decades as a result of many forces. Perhaps the most powerful of these have been advances in our scientific understanding of medical illness and dramatic new opportunities for intervention in the treatment of both acute and chronic illness. These interventions are in large part "medical" and include major new advances in clinical pharmacology. They are also what our predecessors might have considered "surgical," since more and more internists are getting involved in highly technical invasive procedures, both diagnostic and procedural.

We have also made significant advances in understanding the behavioral basis of illness and health. Internists have played a leading role in research documenting the impact of nutrition, exercise, smoking and other behavioral components of health and are valued as counselors about prevention, as well as managers of chronic illness. The internist is the only specialist for adults who can be both a highly focused expert in a subspecialty area and a generalist who provides comprehensive primary care to patients with many different kinds of problems.

Given this breadth, it is not surprising that internal medicine needs a carefully defined curriculum for its trainees. For years, program directors have been creating their own, adding new elements—from molecular biology to biofeedback—in response to external requirements and their sense of what is important for patient care.

However, the training period has remained fixed at three years, and it has become harder and harder to fit in these new components and still allow residents to sleep, eat, or breathe! A comprehensive curriculum is needed to help us make sense of the breadth of knowledge, to set priorities and to respond to change.

To create its resource document, FCIM brought together subspecialists and generalists from around the country for a process that lasted more than two years. Every person who wanted a new area included in the curriculum had to present his case to numerous people. Arguments were examined and decisions were made collaboratively.

The curriculum represents a true consensus of our discipline, and it includes a wide variety of ambulatory specialties that might not have been included in the internal medicine curriculum or textbooks of 10 or 20 years ago. Office gynecology, orthopedics, ENT, substance abuse, domestic violence, urinary incontinence, Alzheimer's disease, palliative care, ethics, and much more have been added alongside traditional internal medicine subspecialties.

The inclusion of this material is exciting to young people entering internal medicine because it promises to give them the ability to provide comprehensive primary care to their patients. This material presents the challenge I referred to earlier, and it is somewhat daunting to those of us who have been teaching residents for many years and are trying to imagine how we will teach residents topics about which we ourselves are not very knowledgeable.

The FCIM resource document will help us think about our discipline as we move forward in a competitive environment that is asking us to demonstrate our usefulness to patients, and in which some of the brightest young people are not choosing to go into internal medicine. We should remember that these young people are not intimidated or put off by the breadth of this subject matter but are instead challenged and excited by it. We should respond to that challenge and that excitement.

While it is impossible to do everything in a three-year period, the core attribute of an internist is a love of lifelong learning. Programs will change according to their own resources and priorities. They will now, however, have the FCIM resource document to help guide them. The resource document will also serve as a useful starting ground on which to base national discussion about future directions for graduate training in internal medicine.

One of the most important lessons that came out of the curriculum project was that this needs to be a dynamic process. We fortunately live in the electronic age and can realistically say that this is a living document. We all believe that internal medicine offers the strength of a scientific base, the concern for patient care and the accountability of comprehensive and continuous care. A document like this, which has the ongoing collaboration of all our internal medicine organizations through FCIM, gives us a focus for continuous refinement and improvement.

Because of the breadth and scope of internal medicine and the numerous organizations representing our profession, we sometimes have difficulty speaking with a unified voice. But the FCIM curriculum is more substantial because it is a product of collaboration between numerous internal medicine organizations. It is evidence of our ability to come together over a complex task and forge a communication that will provide a unity of vision for the content and the future of our discipline, its potential for scientific growth and its commitment to patient care. We can describe internal medicine clearly to the public, health plans and purchasers of care. For all of this we should be extremely grateful to the scores of people who took part in this effort. Their hard work will benefit us all.

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