Medical Knowledge Self Assesment Program (MKSAP) -one more time at least

MKSAP 14 has been available for over a year and I finally could resist it no longer and ordered a hard copy of it.I have enjoyed/suffered through all of the previous editions.Even though I am no longer in practice I felt compelled to spend the hours reading the texts and taking the tests-perhaps it gives me a bit of a illusion of still doing what I used to do.

One of the major additions in recent versions of MKSAP is a very large booklet entitled "General Internal Medicine". This section seems to me in part to be the manifestation of the doctrine "Why can't an internist be more like a family doctor?"

There are sections on contraception and abnormal uterine bleeding. When I trained and when I was in practice women who wanted advice about contraception and who had abnormal uterine bleeding were referred to their gynecologist.Very few of the women I saw as patients did not have a gynecologist.

Does the American College of Physicians (ACP) believe and encourage that internists should be adequately expert and trained to go through the vagaries of abnormal uterine bleeding complete with ordering ultrasound and doing a endometrial biopsy? Some of the questions seem to imply just that. Are IM residents trained in this now? At best we internists might be sort-of well read novices in this area and should we not as a matter of professional ethics refer our patients to the specialists who are best able and most expert? Some of the questions in this section seem to assume internists should be able to manage these maters.

I have recently encountered some younger internists who have carved a pseudo-niche in "women's health".These, in my limited experience are mainly female internists, who among other things do the annual paps and help their patients "manage menopause" and offer contraceptive advice. As I have commented on before this is not why I became an internist.Expanding the services I offer perhaps to compete with family doctors and NPs was not something I choose to do.

Internists seemingly are also expected to be able to diagnose and treat various skin disorders including the papulosquamous problems as well as lice and scabies. A section on corneal abrasions implies internists need fluorescein strips and Wood's lights in their office as the expectation is that not only will such patients be evaluated by the internist but treated and the internists will have the patients come back for follow up observation to see if a referral to an opthalmologist is needed.This sounds like the days of gate keeping when every referral needed approval by the insurance clerk.

In spite of the apparent theme that internists need/should/might do many of the things dermatologists and gynecologists do the, MKSAP is a great exercise in reviewing the ever increasing panorama that internal medicine has become. Plus it is probably the only time you will "see" or at least answer a question about a case that turns out to be Whipple's Disease.