Focusing on values in internal medicine, not on names
By Charles K. Francis, FACP
With a nod to William Shakespeare, the question of "what's in a name?" has particular relevance to internal medicine. Throughout its history, internal medicine has struggled to define itself and establish an identity not only for practicing internists, but also for the public, the medical profession and policymakers.
In last month's column, I described how we are linked to the medical ethos that evolved from the Hippocratic traditions of ancient Greece. (See "The College's roots as a vital foundation for its future," online.) I also pointed out that ACP and internal medicine have deep roots in the precepts of the "physician" as defined by London's Royal College of Physicians.
This month, I'd like to discuss how the definition of an internal medicine physician—as distinct from other specialties—has evolved here in the United States.
Building upon the legacy of early English "physicians," internal medicine in the United States was initially influenced by the new knowledge of physiology, biochemistry, anatomy, bacteriology and pathology developing in Germany in the 1880s. Americans borrowed the term used in German to designate the emerging field: Innere Medizin, or internal medicine.
Stressing the field's reliance on scientific experimentation and pathophysiology, the term suggested special training, knowledge and skills. Rather than using the word "physician" to refer to practitioners skilled in the diagnosis and nonsurgical treatment of diseases, a new term—"internist"—was adopted in the United States in the late 1880s. As internal medicine established itself as a specialty, internists became identified with an exclusive field, one that was distinct from surgery, gynecology and general practice.
The scope of that field was further defined by William Osler, MD (1849-1919), who many saw as the archetypical internist. He was known for his extraordinary clinical acumen, unprecedented pathophysiologic insights and exceptional pathologic experience gained through years of performing autopsies on hundreds of the patients he encountered as a consultant and in clinical practice.
In the early 20th century, the Oslerian "consultant-generalist" became the ideal, defining the internist as a clinician whose skills on hospital wards and in the office were enriched by experience in clinical and laboratory investigation and based on pathophysiological understanding.
At the same time, two different sets of diverging pathways were emerging in internal medicine. One was between medical practice and academic medicine; the other was between general internal medicine and the rise of subspecialty medicine.
An early portent of both shifts can be found in the 1901 German internal medicine textbook, "Lehrbuch der inneren Medizin." According to a passage from that book quoted in "The Origin of the Term 'Internal Medicine' " by Arthur Bloomfield, MD, in the April 4, 1959, Journal of the American Medical Association, "The domain of internal medicine has by the accretion of the most various experimental disciplines reached such a scope that one man can no longer be fully authoritative in all its branches. Only the investigator is competent to critically sift the endless accumulation of detail so that the best can be offered to students and general practitioners."
In the wake of reforms stimulated by Abraham Flexner's 1910 report on medical education, departments of medicine and medical school research improved both their quality and importance. By 1920, leadership in internal medicine had begun to shift from clinical practice to medical schools.
With the infusion of federal support for academic research through the 1960s, the definition of an internist no longer focused exclusively on the role of the hospital-based consultant-generalist. It now included a new dimension, that of the medical school-based researcher, or "clinical investigator."
To help reflect the growing standards of academic internal medicine, ACP in 1936 helped establish the American Board of Internal Medicine, working to put in place a certification process to define and regulate the standards of the specialty.
Board certification in the medical subspecialties consequently followed. However, subspecialty certification could be obtained only after a physician had practiced general internal medicine for a specific period. That development helped relegate general internal medicine to a nonconsultative role and elevate medical subspecialties to a more prestigious, consultant status.
It also created another definition of an internist: a "medical subspecialist." Not surprisingly, as the nexus of research and medical practice shifted from practice to medical schools, general internal medicine declined as a provider of hospital care, as a focus of medical education and as an object of clinical investigation.
The advent of primary care
While the trend toward specialization continued through the 1970s, a new discipline was created: primary care. Instead of distinguishing internal medicine from other specialties, primary care for the first time placed the specialty in a shared province with family practice, general pediatrics and obstetrics and gynecology.
Ostensibly to fill a major societal need, the primary care physician would provide care that was accessible, comprehensive, coordinated, continuous, accountable and humane. In an effort to promote primary care and increase participation in the new field by internists, federal support for general internal medicine training was increased significantly, while general internal medicine divisions were established in medical schools. In many departments of medicine, general internists became the major clinician-teachers and health services researchers.
Not accidentally, the promotion of primary care coincided with the rise of health care cost containment as a national priority. Under managed care, the general internist would be expected (and paid?) to reduce unnecessary procedures, unneeded hospitalizations and expensive subspecialty referrals. The valuable role of internal medicine education notwithstanding, the general internist—along with family physicians, pediatricians and ob/gyns—was newly defined once again, this time as "gatekeeper."
Today, we know that actual experience has not borne out the fundamental assumptions about the mutual benefits of primary care and managed care. Challenged by increasing knowledge about the human genome and the prospect of ongoing health care reform, is primary care a viable construct in our rapidly changing health care environment?
We need to devote a great deal of effort, both collectively through the College and as individual physicians, to answering that question. It's clear that attempts to establish one unifying definition—as "physician," internist, clinical investigator, subspecialist, gatekeeper, primary care provider or even "Doctor for Adults"—have been confounded by the unpredictable influences of the cultural, educational, financial and political environments in which internists have found themselves throughout history.
How will the definition of internal medicine evolve? Hal C. Sox, MACP, Editor-in-Chief of Annals of Internal Medicine, wrote in the Feb. 4, 2003, issue of that journal, "The American people want a regular physician who knows their medical history and knows them as a person."
"Internal medicine's attempts to reach a unifying definition of the specialty may have been undermined by the focus on names that connoted specific functions, rather than on the specialty's traditional values and ethos."
The authors of another article in that same issue of Annals wrote that "greater attention is needed for the essential 'core values' of primary care. Perhaps primary care's overarching focus should be on values and ethos, not solely on functions because these functions will vary substantially in the future. Just as all of medicine has sought to unify the profession by focusing on core values of professionalism, primary care may need to do the same."
For more than a century, internal medicine's attempts to reach a unifying definition of the specialty may have been undermined by the focus on names that connoted specific functions, rather than on the specialty's traditional values and ethos.
The characteristics that supposedly define primary care—care that is comprehensive, accessible, coordinated, continuous and accountable—have been the fundamental tenets of internal medicine, especially general internal medicine, through the years, long before the advent of primary care.
Regardless of the particular name we use to identify a specialist in internal medicine—general internist, subspecialist, hospitalist, investigator or primary care physician—the core values of internal medicine remain the same: a basis in science, adherence to high academic standards and patient-centered care. Those values will continue to serve as the integrating force for all internists, regardless of their name or function.
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