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Internal medicine is the medical specialty concerned with the diagnosis and nonsurgical treatment of unusual or serious diseases, especially where there is difficulty in diagnosis or management. In North America, specialists in internal medicine are commonly called internists. Elsewhere, especially in Commonwealth nations, such specialists are often called physicians, in the older, narrow sense of the word (in North America, physician now commonly applies to any medical practitioner).
Because their patients are often seriously ill or require complex
investigations, internists do much of their work in hospitals. Many are
in consultant practice, only seeing patients referred by other medical
practitioners, to help solve complex problems. Because of this
tradition, internists have sometimes been described as the "doctor's
doctor".
Formerly, many internists were not subspecialized (general physicians in Commonwealth parlance), and would see any complex nonsurgical problem; this style of practice has become much less common.
In modern urban practice, most internists are subspecialists: that
is, they generally limit their medical practice to problems of one
organ system or to one particular area of medical knowledge. For
example, gastroenterologists and nephrologists specialize respectively in diseases of the gut and the kidneys.
Internists have a lengthy clinical and scientific training in their
areas of medical interest, and have special expertise in the use of
drugs or other medical therapies (as opposed to surgery).
While the name "internal medicine" may suggest that internists only
treat problems of "internal" organs, this is not the case. Internists
are trained to treat patients as whole people, not mere organ systems.
Definition of an internist
Internists hold a medical degree. They are not to be confused with "medical interns," who are either physicians in their first year of residency training (in countries like the USA), or final-year medical students (in countries like Colombia). Although Internists may act as primary care physicians,
they are not "family physicians," "family practitioners," or "general
practitioners" (whose training in certain countries includes the
medical care of children, and may include surgery, obstetrics and
pediatrics). General Internists practice medicine from a primary care
perspective but they can treat and manage many ailments and are usually
the most adept at treating a broad range of diseases affecting adults.
Internal Medicine subspecialists may also practice general internal
medicine, but can focus their practice on their particular subspecialty
like cardiology or pulmonology after completing a fellowship. (Additional training of 2-3 years)
In the USA,
adult primary care is usually provided by either family practice or
general internal medicine physicians. The primary care of adolescents
is provided by family practice, internists and pediatricians. The
primary care of children and infants is provided by Family Practice or
Pediatricians, thus, there is overlap. These physicians can have either
an MD,DO, MBBS, MBChB, BMBS, BMed, MBBChir, Degree.
Caring for the whole patient
Internists are trained to solve puzzling diagnostic problems and
handle severe chronic illnesses and situations where several different
illnesses may strike at the same time. They also bring to patients an
understanding of preventive medicine, men's and women's health,
substance abuse, mental health, as well as effective treatment of
common problems of the eyes, ears, skin, nervous system and
reproductive organs. Most older adults in the United States see an
internist as their primary physician.
Education and Training of Internists
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The training and career pathways for internists vary considerably across the world.
First, they must receive the "entry-level" education required of any
medical practitioner in the relevant jurisdiction. In all developed
countries, entry-level medical education programs are tertiary-level courses, undertaken at a medical school attached to a university. Depending on jurisdiction and university, entry may follow directly from secondary school or require pre-requisite undergraduate education.
The former commonly take five or six years to complete. Programs that
require previous undergraduate education are usually four or five years
in length. Hence, gaining a basic medical degree may typically take
from five to eight years, depending on jurisdiction and university.
Following completion of entry-level training, newly graduated
medical practitioners are often required to undertake a period of
supervised practice before full licensure, or registration, is granted, typically one or two years. This period may be referred to as "internship"
or "conditional registration". Then, internists require specialist
training in internal medicine or one of its subspecialities. In North
America, this postgraduate training is often referred to as residency training; in Commonwealth countries, such trainees are often called registrars.
Training in medical specialties typically takes from three to six
years, and sometimes more, depending on specialty and jurisdiction. Any
medical practitioner who completes specialist training in internal medicine (or in one of its subspecialties) is an internist, or a specialist physician
in the older, narrower sense. In some jurisdictions, training in
internal medicine is begun immediately following completion of
entry-level training, or even before. In other jurisdictions, junior
medical doctors must undertake generalist (un-streamed) training for
one or more years before commencing specialization. Hence, depending on
jurisdiction, an internist (specialist physician) often does not
achieve recognition as a specialist until twelve or more years after
commencing basic medical training — five to eight years at university
to obtain a basic medical qualification, and up to another six years to
become a specialist.
Subspecialties of internal medicine
Internists can choose to focus their practice on general internal
medicine, or may take additional training to "subspecialize" in one of
13 areas of internal medicine, generally organized by organ system.
Cardiologists, for example, are doctors of internal medicine who
subspecialize in diseases of the heart. The training an internist
receives to subspecialize in a particular medical area is both broad
and deep. Subspecialty training (often called a "fellowship") usually
requires an additional one to three years beyond the standard three
year general internal medicine residency. (Residencies come after a
student has graduated from medical school.)
In the United States,
there are two organizations responsible for certification of
subspecialists within the field, the American Board of Internal
Medicine, and the American Osteopathic Board of Internal Medicine.
The following are the subspecialties recognized by the American Board of Internal Medicine[1].
- Cardiology, dealing with disorders of the heart and blood vessels
- Endocrinology, dealing with disorders of the endocrine system and its specific secretions called hormones
- Gastroenterology, concerned with the field of digestive diseases
- Hematology, concerned with blood, the blood-forming organs and its disorders
- Infectious disease, concerned with disease caused by a biological agent such as by a virus, bacterium or parasite
- Medical oncology, dealing with the study and treatment of cancer
- Nephrology, dealing with the study of the function and diseases of the kidney
- Pulmonology, dealing with diseases of the lungs and the respiratory tract
- Rheumatology, devoted to the diagnosis and therapy of rheumatic diseases.
The ABIM also recognizes additional qualifications in the following areas
Internists may also specialize in allergy and immunology. The
American Board of Allergy, Asthma, and Immunology is a conjoint board
between internal medicine and pediatrics.
The American College of Osteopathic Internists recognizes the following subspecialties. [2]
Principles of diagnosis
The main tools of the doctors are the medical history and the physical examination,
but this holds particularly true for internal medicine. Subtle
descriptions of disease (e.g. cyclic shallow and deep breathing, as in
Cheyne-Stokes's respiration, or persistently deep breathing as in
Kussmaul's) or physical signs (e.g. clubbing
in many internal diseases) are important tools in guiding the
diagnostic process. In the medical history, the "Review of Systems"
serves to pick up symptoms of disease that a patient might not normally
have mentioned, and the physical examination typically follows a
structured fashion.
At this stage, a doctor is generally able to generate a differential diagnosis, or a list of possible diagnoses that can explain the constellation of signs and symptoms. Occam's razor
dictates that, when possible, all symptoms should be presumed to be
manifestations of the same disease process, but often multiple problems
are identified.
In order to "narrow down" the differential diagnosis, blood tests and medical imaging are used. They can also serve screening purposes, e.g. to identify anemia in patients with unrelated complaints. Commonly performed screening tests, especially in older patients, are an X-ray of the chest, a full blood count, basic electrolytes, renal function and blood urea nitrogen.
At this stage, the physician will often have already arrived at a
diagnosis, or maximally a list of a few items. Specific tests for the
presumed disease are often required, such as a biopsy for cancer, microbiological culture etc.
Treatment
Medicine is mainly focused on the art of diagnosis and treatment with medication, but many subspecialties administer surgical treatment:
Pulmonology: Bronchoscopy
See also
External links
Classical
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