To revitalize internal medicine, look back to its roots
By Munsey S. Wheby, FACP
There's a crisis of sorts brewing in medicine. It's not a crisis of dollars, of access to care for the uninsured, or even of our country's stubbornly unsystematic "system" of health care.
The crisis I'm describing hits much closer to home and is at the heart of our specialty. It affects our professional identity, our satisfaction and our professional succession. The issue: Who are internists, what is internal medicine today, and what does it mean for a young medical graduate to become an internist in the 21st century?
With fewer medical students choosing internal medicine as a career, the College has undertaken a new initiative to revitalize internal medicine. The effort, which will be led by Board of Regents Chair Mary T. Herald, FACP, will not limit its mission to confronting internal medicine's waning appeal among medical students. Dr. Herald and her working group will also confront the fact that many practicing internists seem uncertain of—and unhappy with—their particular niche in medicine.
In November, the College will host a summit conference to address these concerns. We will bring together internal medicine educational organizations and subspecialty societies, as well as representatives from private and academic practices.
As the summit nears, it occurs to me that we as a specialty may need to look back in order to look forward. To see more clearly who we are now as internists and who we will be in the future, we should first refresh our understanding of internal medicine's origins and heritage.
The early years of internal medicine
For an historical perspective, I'd like to turn to a 1995 Governor's newsletter from ACP's Georgia Chapter. As Osler scholar Mark E. Silverman, MACP, pointed out, the term "internal medicine" was derived more than 100 years ago from the German term Innere Medizin.
Innere Medizin was coined in the 1880s to denote a special, scientifically-based knowledge of organ pathophysiology and the interior workings of the body. Physicians whose practice and therapeutics were based on the new scientific developments then occurring largely in German universities were said to be practicing Innere Medizin. Because of its newfound rigorous scientific foundation, Innere Medizin was a breed of medicine apart from the empirically based practice of late 19th-century general practitioners.
Physicians practicing Innere Medizin became the first internists. From the start, however, the English sobriquet internist was not well understood, causing concern and confusion even in the early years. As Dr. Silverman noted, Sir William Osler registered his opinion on the ambiguous terminology in 1897:
I wish there were another term to designate the wide field of medical practice which remains after the separation of surgery, midwifery, and gynaecology. Not itself a specialty, (though it embraces at least half a dozen), its cultivators cannot be called specialists, but bear without reproach the good old name physician, in contradistinction to general practitioners, surgeons, obstetricians and gynaecologists.
Here Osler calls a "physician" what we today know as a "general internist," and he laments that this generic term must do double duty to identify both the internist and the nonsurgical doctor. While Osler did not look upon internist "physicians" as specialists per se, he did distinguish them from "general practitioners." Thus one could argue that his internist "physicians" were truly specialists in internal medicine.
I remember that in the 1940s and 1950s, internists were recognized and celebrated as diagnosticians. Internists were the premier medical problem-solvers, the "doctors' doctors" who other physicians relied on to refer perplexing adult patients.
It was internists' generous fund of knowledge and powers of observation, intellect and deductive reasoning that set them apart, Sherlock Holmes-like, from the rest of the profession. I like to think that we can still lay claim to that special skill set and approach.
The perception of the internist as a specialist in diagnosis persisted in the 1950s and early 1960s, when I was in medical school and residency. Even those internists who chose further training in specific subsets of internal medicine were thought of—and thought of themselves—as internists first, and only then as subspecialists of various stripes.
The rise of subspecialties
In time, though, expanding knowledge and the explosive growth of technologies gave rise to various medical subspecialties as formal disciplines. In turn, these subspecialties developed their own training, specialized study, and highly specific skills and procedures.
These practitioners narrowed their clinical focus to care chiefly for patients with problems in one or another distinct organ system. The introduction of subspecialty board certification requirements further contributed to the rise of subspecialists. For many of these physicians, being an internist became simply a background qualification, not an identifier.
By the late 1980s, the concept of the internist as a specialist in internal medicine was even further nuanced (some would say eroded) by managed care. Health plans required members to designate a primary care physician. To compete for patients in those plans, internists became part of the pool of "primary care physicians," a label they shared with family medicine physicians who are not specialists, but generalists.
(Even the College's "Doctors for Adults" campaign and Web site carried the following message: "An internist, just like a family practice or general practice doctor, can serve as your primary care doctor." While this is an accurate statement—and it's true that we need all kinds of primary care physicians—it further confuses our effort to define who an "internist" is.)
In fact, over the last several decades, we seem to have stopped using "internist" as a defining term. Even as various internal medicine subspecialties have evolved, "internist" has devolved to mean a general internist. I still consider the internist a specialist in internal medicine (to my mind, adding the word "general" only muddies the term), but this is not how the public, or much of the profession, now understands it.
An identity problem
While the name internist poses a problem, the specialty faces even more serious issues of identity. Our specialty seems to have lost some of its sense of itself, both in terms of taking a distinct approach to patient care and in terms of meeting a set of specific expectations patients might have.
As long as we are uncertain of what exactly defines us and sets us apart from other specialties, it's hard to make the case for our field with students and residents. It can even be hard sometimes to sustain in ourselves a strong sense of identity and professional commitment.
I suggest we keep reminding ourselves of the deductive approach and set of skills first identified in German universities more than a century ago. The internist's mode of thinking, whatever the setting, is grounded in extensive knowledge of pathophysiology and anchored by a careful history and physical examination. The internist's approach to the patient is comprehensive, always compassionate and evidence-based, with judgment that is as informed by art as science.
Our thinking is intellectual, organized and disciplined, and never driven solely by algorithm. In some urgent-care settings today, algorithm-based approaches to patient care are producing inadequate, even skimpy, use of the history and physical, as well as an over-reliance on technological diagnostic tests. That approach is burdensome to the patient, expensive and further dilutes our core strengths.
Training programs in internal medicine must re-dedicate themselves to teaching patient-focused, targeted investigation based on thorough knowledge of pathophysiology, as well as on an attentive history and physical examination. This approach is the key to achieving the best care for patients, making optimal yet judicious use of resources and, not insignificantly, honing the internist's specific clinical acumen and judgment over time.
If we are to attract more top-notch medical students to careers in internal medicine, we who are internal medicine's role models in both academic and private practice must show that we are excited about, proud of and professionally fulfilled by our work. Students need to see first-hand how we savor and meet the intellectual challenges of diagnosis, how we value keen powers of observation and judgment, how we feel called to give compassionate and skillful care to patients.
Students must also see us as agents of our own professional destiny, striving to change those things that now hamper our work and dampen our spirit. They must see us succeed in improving the practice environment by working to reduce or streamline bureaucratic demands on our time and attention, and by advocating for and achieving more equitable physician reimbursement. Not only must they see us meet the challenges of inevitable change, they must see us develop models of practice that are efficient and effective, as well as professionally and personally satisfying. (For more on ACP's efforts to improve the specialty, see "A look at ACP's summit to revitalize internal medicine.")
If we as educators can teach with passion and pride what we know best as internal medicine, we have a good chance of inspiring and tutoring a new generation of internists and thus revitalizing our specialty. We also stand to better know who we are as internists and thus of revitalizing ourselves.
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