Should Internal Medicine and Family Medicine Be Merged as a Single Specialty?

Robert W. Morrow, MD; Robert M. Centor, MD; Robert W. Donnell, MD; Bradley P. Fox, MD

Disclosures

March 25, 2009

In This Article

The question posed to our Roundtable board, a mix of internists and family medicine physicians, was whether the 2 specialties should be merged.

Robert W. Morrow, MD - Family Medicine

Robert W. Morrow, MD, is a family physician and regular contributor to Medscape via his video blog TheTransparent Practice. He opens this Roundtable with a blog on the subject posed to our Roundtable board: Should family medicine and internal medicine be merged into a single specialty?

Robert M. Centor, MD - Internal Medicine

Recently, some have suggested that internal medicine and family medicine should merge as a unified primary care specialty. In an Academic Medicine article, John G. Halvorsen, MD, MS, writes: "The United States remains the only Western industrialized nation that delivers primary care through three major disciplines rather than as a single specialty.[1]" Because many internists call themselves primary care physicians, Dr. Halvorsen has proposed that family medicine, internal medicine, and pediatrics be dissolved and a new primary care specialty created.

I believe that he made the same mistake that many others have made recently; he considered all of primary care as a single concept. However, primary care has many meanings. When a word or phrase has multiple meanings, there is always the potential for misunderstanding.

What is primary care? Is it simple care, episodic care, or triage care? When speaking of primary care, most internists consider its comprehensiveness, complexity, and continuity as well as its focus on chronic care, especially care of older, more complex patients. Internal medicine provides a wonderful balance between left-brain skills and right-brain skills. Good internists revel in difficult diagnoses, evidence-based medicine, and champion patient interactions.

Our training occurs primarily in the hospital, as per the Oslerian tradition, and many internists focus on hospital care, to the exclusion of outpatient care, or they provide a mix. Many internists also subspecialize. Our general training in internal medicine provides a useful preparation for all of this work. We become comfortable with the severe spectrum of illness, and then extrapolate back to our outpatient training.

Family medicine training places more emphasis on broader outpatient skills, such as office orthopaedics, office dermatology, and gynecology. Furthermore, family medicine does not restrict training to adult patients.

I teach both family medicine and internal medicine residents. The best family medicine residents learn much internal medicine, but they have less exposure to it than most internal medicine residents. Internal medicine residencies typically provide 15-18 months of adult inpatient exposure, whereas family medicine residents only have 6-8 months of exposure. One could argue that family medicine training is sufficient, but I believe that acquiring true expertise requires more than the minimum amount of patient exposure.

Internal medicine and family medicine both make important contributions to healthcare. We fill different niches while complementing each other. Both specialties are needed, and there is no need to merge the fields.

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