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

Bradley P. Fox, MD - Family Medicine

The question of the month is whether internal medicine and family medicine should be combined into 1 specialty. When I was asked to take a stand on this, my immediate answer was a resounding "no." I still feel that way. However, the more I thought about it, the more I realized that there might be a different way to answer this question. I need to give the following disclaimer: The proposal about to be presented is not that of any organization to which I belong, nor is it necessarily my opinion. It is a novel way to look at the question that I have been asked, and I hope that it stimulates discussion.

Should internal medicine and family medicine be combined? No. However, one could make the argument that there is no longer a need to have separate residency pathways for internal medicine, family medicine, and even pediatrics. With fill rates for all primary care specialties being low, there is a need to rethink the training process. Furthermore, fewer and fewer residency graduates are content to stay in general internal medicine or general pediatrics. Instead, they are choosing to subspecialize, leaving a dearth in both specialties.

With the coming changes in medicine, there is going to be a greater need for family physicians, general internal medicine physicians, and pediatricians. My proposal would not be to combine internal medicine and family medicine, but to eliminate the general internal medicine and pediatric residencies and train all 3 specialties together.

Here is how it would work: Everyone would enter a family residency for the first 3 years and get a full, well-rounded education. These first 3 years would be relevant to each of the specialties under discussion. For example, because an internist's adult patients may have children, understanding health issues in their children would be important. How often do general internal medicine physicians have to deal with nonpregnancy issues in pregnant women? Having a better understanding of pregnancy would be a valuable part of their practice. For residents who want to be pediatricians, understanding the parents' and grandparents' health issues is important. Education in psychiatry and psychology would be of value to internists, family physicians, and pediatricians; finally, the obstetric (OB) experience could only help in treating pregnant teenagers as well as with newborn care.

After the first 3 years of residency, those going into general internal medicine would then enter a year of internal medicine training only to adults in the hospital and in outpatient offices, focusing on the skills that a general internist needs. The pediatric residents would embark on a year of intense training in the pediatric and neonatal intensive care units and in pediatric office practices. Family medicine residents would be given a choice of 2 pathways -- a fourth year in family medicine with or without OB training. Those who choose OB would continue with an OB continuity practice involving intense training, whereas those who choose the latter course would continue to train in all other aspects of family medicine.

Upon completion of the fourth year, all would be eligible to go into practice. This arrangement would allow for a lower cost of training, as well as a higher number of loan forgiveness packages offered to first-year residents who commit to practicing general family, internal, or pediatric medicine.

I realize that this approach sounds radical, but the more people I bounced it off, the more people who did not think it was such a crazy idea. Think about it. I look forward to reading your responses.

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