CURRENT AND FUTURE STATUS OF INTERNAL MEDICINE.
Professor Ciril Rozman, University Professor of Medicine, Professor Emeritus, University of Barcelona
The recent celebration of the XXVII World Congress of Internal Medicine in Spain prompted me to reflect upon the profound modifications that Internal Medicine has undergone, and how at the same time has enthusiastically upheld its current and future status. I feel greatly honored to have my views published in the International College of Internal Medicine´s website.
William Osler, a great professor of Internal Medicine, in the U.S. and worldwide, predicted in 1897 that during the XX century, Internal Medicine would become the most comprising, in demand and rewarding field of medicine, as well as an excellent career choice for Medical students. This prediction was confirmed, but only for the first 2/3 of the century, being that towards the end, Internal Medicine began to undergo increasing difficulties in determining its profile and limits. Oslo defined the internist as a plural and distinguished generalist. The idea that we´re dealing with a physician who has an extensive view of the patient´s condition is stressed by two terms: generalist and plural. But at the same time, he included the concept of profound knowledge in his definition, using the adjective “distinguished”.
According to William Osler´s prediction, the prestige of Internal Medicine, perceived as such, was immeasurable. The internists held positions of the highest levels at the University as well as the Hospital. Furthermore, they were considered the most prestigious consultants, and consequently were socially and financially successful . In short, the internist had two main characteristics: a) on one hand, given his profound knowledge, he played the role of the top level consultant; and b) on the other hand, for being generalist and plural, he was able to offer his patients comprehensive health care. Midway through the 60´s decade, the disintegration process of Internal Medicine began. From this main stem several medical subspecialities or fields emerged to different degrees. A subspecialist began to act as the top level consultant. The community gradually began to forget the general internist, substituting him with cardiologists, oncologists, neumologists, etc. In addition, a new figure appeared, a specialist in Family and Community Medicine, who presently competes with the Internist in the second aspect, comprehensive health care. In conclusion the internist´s role seems to have lost its meaning.
Before we concern ourselves with Internal Medicine´s validity today, certain semantic precisions are required. Traditionally two kinds of professionals have been distinguished in the field of Internal Medicine: the Specialist in General Internal Medicine and the Specialist in a certain branch of Internal Medicine or Subspecialized Internist. When we examine the U.S. “Boards”, both groups clearly belong to the comprehensive group of specialists in Internal Medicine. Historical evolution has led us to our current situation in which numerous digestologists, cardiologists, neumologists, and other subspecialties no longer consider themselves internists nor are they considered such by General Internists.
In my opinion, it would be worthwhile for all the subspecialists to keep, if not the name, at least the training and the essence of internal medicine. In other words, to be capable of maintaining an integral approach towards the patient, based on profound scientific information. It is apparent, however, that due to our aprehension about the present and future status of Internal Medicine, today´s reality compels us to lean towards the general propensity. In other words, will there be a need for a Specialist in General Internal Medicine in the future, or, as some have suggested, is the Internist in danger of extinction?
I do not like to risk forecasting future events, for fear that feelings and hopes stirred up from last century´s experiences, might overtake me . As I have the strong conviction that we will never experience the same situation as the great professors of Internal Medicine who preceded us, I´m placing my stakes on the future status of Internal Medicine. My reasons are twofold: a) the internist´s competence to practice our profession, in the broadest sense; and b) financial reasons.
The internist is the specialist best prepared to offer his patient primary health care.. A patient is not just the sum of different organic systems for each specialist to examine according to his own area of expertise, but a human being with his bio-psycho-social state of being. The patient´s assorted apparatus or biological systems are interrelated and are influenced furthermore, by the psychic tendancies and social circumstances. Due to the training and generalist orientation, the internist is particularly skillful in perceiving the patient as a person, and not just as a diseased organism. Currently, a new type of “based on evidence” health care is quite popular, and which, by the way, should be denominated, “based on proof”, insomuch as evidence needs no demonstration. It deals with a creditable organization, as the expectation consists of making decisions based on scientific data . Yet, in clinical practice, it is difficult to make an exact evaluation of all the patient´s problems. For this reason, there are new propensities which intend to oppose “based on evidence” health care, that is, the alleged “based on complexity” health care. In my opinion, clinical practice will always be carried out with a degree of uncertainty. The internist tends to possess the necessary clinical art to make intelligent decisions in the most complicated, multmorbid and controversial situations.
The financial aspect constitutes an important factor in the present health care system. Reasons of this nature are beginning to enhance the internist´s image in the United States. The same thing is expected to occur in Spain, when these standards of competence are applied to different professionals in Health Care. A good internist is capable of resolving several health care issues, on his own, which would otherwise require the intervention of diverse specialists, with the resultant increase in value.
In summary, I venture to predict that the internist will continue to be essential, as he has the ability to offer the best primary health care. Furthermore, it is very rewarding to be able to apply this clinical art in the midst of such complexity and uncertainty, and at the same time fulfill these expectations in such a financially profitable manner.
(Note of 2005)