Thursday, January 20, 2011

It seems hard to believe that Internists are asking what is an internist?

Two of my favorite bloggers have recently taken up the questions " what is an internist?". Both Dr. RW (see here) and Dr. DB (see here) have written about this. My speculation is that orthopedists and neurosurgeons are experiencing less of an identity crisis.

My hunch is that both would have much less trouble with that question when they were in their Internal Medicine training programs. ( in fact Dr. RW made that point in his commentary ).

I know I had little doubt about what an internist was and what an internist did when I was a resident in IM. An internist was someone who was respected and called upon to deal with the diagnosis and management of complex medical problems and of critically ill patients. That was what a general internist did.General practitioners would consult with an internist for difficult cases and their expertise and knowledge was respected by both the GPs and surgeons.

Major changes in medical practice has brought about the current ambiguous nature of the internist's identity.

The general internist's role has been bifurcated into an office doctor and a hospitalist, with a rapidly decreasing number of internists playing both roles. While the hospitalist role more closely resembles the internist of 30-40 years ago the office internist is becoming harder and harder to be distinguished from the family practice physician.They both spend a significant part of their day doing preventive medicine,an activity particularity suited to guidelines and flowsheets and readily adaptable to delegation to nurse practitioners and physician assistants and likely ultimately to NP assistants or PA assistants.

The family practice physicians has evolved from the GP s of years ago and while the GPs were a source of referrals to the internist the Family Practice docs are more often than not competitors in the fairly recently defined world of what has become to be known as "primary care practice" . Both FP and IM docs will face more competition from NP and PAs if and when Obamacare plays out as demand from the number of insurance card carrying patients increasingly outpaces the supply of FPs and general IM docs and likely NPs as well.

The earlier version of the internist practiced in a very different world. He took call at night and would go to the hospital to see his patients in the ED and if they had problems in the hospital and some went to nursing homes.

The modern version so often now signs out at five o'clock with a telephone answering device informing the caller to call back during regular hours or if "an emergency" go to the Emergency Department.

I found the following paragraph from Dr RW's commentary as on target as it is depressing to someone who spend many years training to be an internist and more years practicing internal medicine as it used to be and now watching it change almost to the point of being unrecognizable.

The American College of Physicians slogan “Doctors for Adults” is unfortunate because it defines Internal Medicine as Family Practice without Pediatrics. This view has led to a proposal, published in the Journal Academic Medicine, that IM and FP be merged. It would mean the dissolution of general IM as a specialty. It's little wonder so few trainees want to go into general IM anymore. Who in their right mind would sign up for a specialty that's slated for dissolution in the next decade.

I know I would not.

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