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

Robert W. Donnell, MD - Internal Medicine

Just look at what has happened to internal medicine. On page 7 of Sapira's Art and Science of Bedside Diagnosis[2] we find this definition:

(1) ( Obsolete) That nonsurgical medical specialty concerned with clinical diagnosis and scientific therapy. Previously a secondary-care consultant specialty, it underwent crisis by lysis in the late 1960s; (2) ( contemporary) a biopolitical consortium of balkanized tertiary nonsurgical subspecialties, which, oxymoronically, claim it to be a primary care specialty.

Internal medicine has fallen on difficult times. It is in danger of losing its identity as a unique specialty. Managed care and other economic forces spurred the rising popularity of "Med-Peds," thus blurring the distinction between internal medicine and family practice. Those same economic forces led internal medicine to devolve from an in-depth consulting specialty into a primary care discipline. Its professional societies have been of little help, unable to even develop a suitable slogan to promote the specialty. For example, the American College of Physicians, it seems, can do no better than "Doctors for Adults."

With internal medicine thus characterized as "family practice minus obstetrics, gynecology, and pediatrics," it's clear why some would question the value of general internal medicine as a specialty and propose that it be merged with family practice. Dr. Halvorsen's article in Academic Medicine that proposed the merger describes the resulting hybrid specialty[1]:

Because the new discipline would provide continuous, comprehensive health care for an individual through his or her entire lifetime, it would naturally incorporate models and processes of care that integrate the known effects of genetic factors, health risks, lifestyle choices, prenatal and natal factors, and disease processes over a person's complete lifespan. From a professional perspective, additional efficiency and cost saving would also be gained by creating a single set of standards and mechanisms for initial board certification and continued maintenance of certification.

This "new discipline" describes nothing more than family practice. In effect, the proposal would dissolve general internal medicine as a specialty.

Does general internal medicine warrant recognition as a distinct specialty? Detractors would cite the extensive overlap between internal medicine and family practice. However, that reason alone is not a convincing argument for the merging of specialties. Overlap among specialties is common in medicine. For example, hypertension and dyslipidemia are treated by gynecologists, family practitioners, internists, cardiologists, and endocrinologists. The answer requires an examination of the essential characteristics of internal medicine in a historical context.

In the 19th century, generalist physicians in the United States began to differentiate themselves as consultants. They adopted the German principle of innere Medizin, in which the practice of medicine was based on an in-depth knowledge of pathophysiology.[3] William Osler advanced the idea and codified it in his textbook The Principles and Practice of Medicine.[3] In this model, the internist became known as the consultant-generalist, emphasizing a special depth of knowledge across a wide domain of nonsurgical illnesses in adult patients.[4]

The notion of internal medicine, then, carries with it a degree of special expertise in the diagnosis and management of complex problems. Advances in medical treatment and an aging population have changed the demographics of patient care. Patients with complex problems are presenting in larger numbers. The need for expertise in treatment cannot entirely be met by the subspecialties, because such patients have undifferentiated presentations and their problems span multiple organ systems. Therefore, the specialty of internal medicine is based on the model of consultant-generalist and is as relevant today as ever.

Unfortunately, there is considerable momentum toward the dissolution of general internal medicine. Fewer and fewer trainees are choosing it as a career. Now that a proposal to merge internal medicine with family practice has been made public,[1] the decline in interest in general internal medicine will likely accelerate. Think about it. Who would want to sign up with a specialty that may be eliminated in 20 years?

Our professional societies have failed in representing internal medicine as a specialty. Unless they take quick and decisive action in advocating the internist as consultant-generalist, the decline of internal medicine will continue.

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