Internal medicine

Internal medicine or general internal medicine (in Commonwealth nations) is the medical specialty dealing with the prevention, diagnosis, and treatment of internal diseases. Doctors specializing in internal medicine are called internists, or physicians (without a modifier) in Commonwealth nations. Internists are skilled in the management of patients who have undifferentiated or multi-system disease processes. Internists care for hospitalized and ambulatory patients and may play a major role in teaching and research. Internal medicine and family medicine are often confused as equivalent in the Commonwealth nations (see below).

Because internal medicine patients are often seriously ill or require complex investigations, internists do much of their work in hospitals. Internists often have subspecialty interests in diseases affecting particular organs or organ systems.

Internal medicine is also a specialty within clinical pharmacy and veterinary medicine.

Etymology and historical development

The etymology of the term internal medicine in English is rooted in the German term Innere Medizin from the 19th century.[1] Internal medicine was initially characterized by determination of the underlying "internal" or pathological causes of symptoms and syndromes by use of laboratory investigations in addition to bedside clinical assessment of patients. In contrast, physicians in previous generations, such as the 17th-century physician Thomas Sydenham, who is known as the father of English medicine or "the English Hippocrates", had developed nosology (the study of diseases) via the clinical approach of diagnosis and management, by careful bedside study of the natural history of diseases and their treatment.[2] Sydenham eschewed dissection of corpses and scrutiny of the internal workings of the body, for considering the internal mechanisms and causes of symptoms.[3] It was thus subsequent to the 17th century that there was a rise in anatomical pathology and laboratory studies, with Giovanni Battista Morgagni, an Italian anatomist of the 18th century, being considered the father of anatomical pathology.[4] Laboratory investigations became increasingly significant, with contribution of doctors including German physician and bacteriologist Robert Koch in the 19th century.[5] The 19th century saw the rise of internal medicine that combined the clinical approach with use of investigations.[6] Many early-20th-century American physicians studied medicine in Germany and brought this medical field to the United States. Thus, the name "internal medicine" was adopted in imitation of the existing German term.[1]

Historically, some of the oldest traces of internal medicine can be traced from ancient India and ancient China.[7] Earliest texts about internal medicine are the Ayurvedic anthologies of Charaka.[8]

Role of internal medicine physicians

Internal medicine specialists, also known as general internal medicine specialists or general medicine physicians in Commonwealth countries,[9] are specialist physicians trained to manage particularly complex or multisystem disease conditions that single-organ-disease specialists may not be trained to deal with.[10] They may be asked to tackle undifferentiated presentations that cannot be easily fitted within the expertise of a single-organ specialty,[11] such as dyspnea, fatigue, weight loss, chest pain, confusion or change in conscious state.[9] They may manage serious acute illnesses that affect multiple organ systems at the same time in a single patient, and they may manage multiple chronic diseases that a single patient may have.[10]

General internal medicine specialists do not provide necessarily less expertise than single-organ specialists, rather, they are trained for a specific role of caring for patients with multiple simultaneous problems or complex comorbidities.[11]

Perhaps because it is complex to explain treatment of diseases that are not localised to a single-organ, there has been confusion about the meaning of internal medicine and the role of an "internist".[12] Internists are qualified physicians with postgraduate training in internal medicine and should not be confused with "interns",[13] who are doctors in their first year of residency training (officially the term intern is no longer in use).[14][15] Although internists may act as primary care physicians, they are not "family physicians", "family practitioners", or "general practitioners", or "GPs", whose training is not solely concentrated on adults and may include surgery, obstetrics, and pediatrics. The American College of Physicians defines internists as "physicians who specialize in the prevention, detection and treatment of illnesses in adults".[16]

Education and training of internists

The training and career pathways for internists vary considerably across the world.

Many programs require previous undergraduate education prior to medical school admission. This "pre-medical" education is typically four or five years in length. Graduate medical education programs vary in length by country. Medical education programs are tertiary-level courses, undertaken at a medical school attached to a university. In the United States, medical school consists of four years. Hence, gaining a basic medical education may typically take 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 the licensure, or registration, is granted, typically one or two years. This period may be referred to as "internship", "conditional registration", or "foundation programme". Then, doctors may finally follow specialty training in internal medicine if they wish, typically being selected to training programs through competition. In North America, this period of postgraduate training is referred to as residency training, followed by an optional fellowship if the internist decides to train in a subspecialty.

In the United States and in most countries, residency training for internal medicine lasts three years and centers on secondary and tertiary levels of care. In Commonwealth countries trainees are often called senior house officers for four years after the completion of their medical degree (foundation and core years). After this period, they are able to advance to registrar grade when they undergo a compulsory subspecialty training (including acute internal medicine or a dual subspecialty including internal medicine). This latter stage of training is achieved through competition rather than just by yearly progress as the first years of postgraduate training.[17][18]

Certification of specialists

In the United States, three organizations are responsible for the certification of trained internists (i.e., doctors who have completed an accredited residency training program) in terms of their knowledge, skills, and attitudes that are essential for excellent patient care: the American Board of Internal Medicine, the American Osteopathic Board of Internal Medicine and the Board of Certification in Internal Medicine.

Subspecialties

United States

In the United States, two organizations are responsible for certification of subspecialists within the field: the American Board of Internal Medicine and the American Osteopathic Board of Internal Medicine. Physicians (not only internists) who successfully pass board exams receive "board certified" status.

American Board of Internal Medicine

The following are the subspecialties recognized by the American Board of Internal Medicine.[19]

Neurocritical Care

  • Pulmonary Disease, dealing with diseases of the lungs and the respiratory tract
  • Rheumatology, devoted to the diagnosis and therapy of rheumatic diseases
  • Sleep medicine
  • Sports medicine
  • Transplant hepatology

American College of Osteopathic Internists

The American College of Osteopathic Internists recognizes the following subspecialties:[21]

United Kingdom

In the United Kingdom, the three medical Royal Colleges (the Royal College of Physicians of London, the Royal College of Physicians of Edinburgh and the Royal College of Physicians and Surgeons of Glasgow) are responsible for setting curricula and training programmes through the Joint Royal Colleges Postgraduate Training Board (JRCPTB), although the process is monitored and accredited by the General Medical Council (which also maintains the specialist register).

Doctors who have completed medical school spend two years in foundation training completing a basic postgraduate curriculum. After two years of Core Medical Training (CT1/CT2), or three years of Internal Medicine Training (IMT1/IMT2/IMT3) as of 2019, since and attaining the Membership of the Royal College of Physicians, physicians commit to one of the medical specialties:[22]

  • Acute medicine (with possible accreditations in stroke medicine or pre-hospital emergency medicine)
  • Allergy
  • Audiovestibular medicine
  • Cardiology (with possible accreditation in stroke medicine)
  • Clinical genetics
  • Clinical neurophysiology
  • Clinical Pharmacology and Therapeutics (with possible accreditation in stroke medicine)
  • Dermatology
  • Endocrinology and diabetes mellitus
  • Gastroenterology (with possible accreditation in hepatology)
  • General (internal) medicine (with possible accreditation in metabolic medicine or stroke medicine)
  • Genito-urinary medicine
  • Geriatric medicine (with possible accreditation in stroke medicine)
  • Haematology
  • Immunology
  • Infectious diseases
  • Medical oncology (clinical or radiation oncology falls under the Royal College of Radiologists, although entry is through CMT and MRCP is required)
  • Medical ophthalmology
  • Neurology (with possible accreditation in stroke medicine)
  • Nuclear medicine
  • Paediatric cardiology (the only pediatric subspecialty not under the Royal College of Paediatrics and Child Health)
  • Palliative medicine
  • Pharmaceutical medicine
  • Rehabilitation medicine (with possible accreditation in stroke medicine)
  • Renal medicine
  • Respiratory medicine
  • Rheumatology
  • Sport and exercise medicine
  • Tropical medicine

Many training programmes provide dual accreditation with general (internal) medicine and are involved in the general care to hospitalised patients. These are acute medicine, cardiology, Clinical Pharmacology and Therapeutics, endocrinology and diabetes mellitus, gastroenterology, infectious diseases, renal medicine, respiratory medicine and often, rheumatology. The role of general medicine, after a period of decline, was reemphasised by the Royal College of Physicians of London report from the Future Hospital Commission (2013).[23]

Medical diagnosis and treatment

Medicine is mainly focused on the art of diagnosis and treatment with medication, but many subspecialties administer procedural treatment:

  • Cardiology: angioplasty, cardioversion, cardiac ablation, intra-aortic balloon pump
  • Critical care medicine: mechanical ventilation
  • Gastroenterology: endoscopy and ERCP
  • Nephrology: dialysis
  • Pulmonology: bronchoscopy

See also
  • Royal Australasian College of Physicians
  • Royal College of Physicians and Surgeons of Canada

References
  1. Echenberg, D. (2007). "A history of internal medicine: medical specialization: as old as antiquity". Rev Med Suisse. 3 (135): 2737–9. PMID 18214228.
  2. Meynell, G.G. (2006). "John Locke and the preface to Thomas Sydenham's Observationes medicae". Medical History. 50 (1): 93–110. doi:10.1017/s0025727300009467. PMC 1369015. PMID 16502873.
  3. "Brought to Life: Exploring the History of Medicine: Thomas Sydenham (1624-89)". Science Museum, London. Archived from the original on 14 August 2017. Retrieved 17 May 2017.
  4. Morgagnu, G.B. (1903). "Founders of Modern Medicine: Giovanni Battista Morgagni. (1682–1771)". Medical Library and Historical Journal. 1 (4): 270–277. PMC 1698114. PMID 18340813.
  5. "Robert Koch". Encyclopaedia Britannica. Retrieved 26 June 2017.
  6. Berger, Darlene (1999). "A brief history of medical diagnosis and the birth of the clinical laboratory: Part 1—Ancient times through the 19th century" (PDF). MLO Med Lab Obs. 31 (7): 28–30, 32, 34–40. PMID 10539661. Retrieved 2018-06-26.
  7. United States. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. p. 12.
  8. Frank Joseph Goes. The Eye in History. JP Medical Ltd. p. 93.
  9. Poole, Philippa. "Restoring the Balance - The Importance of General Medicine in the New Zealand Health System". Internal Medicine Society of Australia and New Zealand. Retrieved 27 June 2018.
  10. "General and Acute Care Medicine". The Royal Australasian College of Physicians. Retrieved 27 June 2018.
  11. Lowe, J.; Candlish, P.; Henry, D.; Wlodarcyk, J.; Fletcher, P. (2000). "Specialist or generalist care? A study of the impact of a selective admitting policy for patients with cardiac failure". Int J Qual Health Care. 12 (4): 339–45. doi:10.1093/intqhc/12.4.339. PMID 10985273.
  12. Freeman, Brian S. (2012). The ultimate guide to choosing a medical specialty (3rd ed.). New York: McGraw-Hill Medical. pp. 229–250. ISBN 978-0071790277.
  13. Arneson, J; McDonald, WJ (July 1998). "Can we educate the public about internal medicine? Initial results". The American Journal of Medicine. 105 (1): 1–5. doi:10.1016/S0002-9343(98)00220-4. PMID 9688013.
  14. "What is an Internist - Doctors for Adults". American College of Physicians. Retrieved 4 Apr 2012.
  15. "Glossary of Terms" (PDF). ACGME. June 28, 2011. Archived from the original (PDF) on 15 November 2012. Retrieved 2 December 2012.
  16. "ACP: Who We Are". American College of Physicians. Retrieved 2011-03-30.
  17. Freeman 2012, pp. 236
  18. Schierhorn, Carolyn (Dec 6, 2012). "Like to puzzle over diagnoses? Internal medicine may be for you". The DO. Archived from the original on October 20, 2013.
  19. "abim.org". Retrieved 2022-01-26.
  20. "aaaai.org". Retrieved 2015-07-08.
  21. "Subspecialty Section Membership | American College of Osteopathic Internists".
  22. "Approved specialty and subspecialty training curricula by Royal College". General Medical Council. Retrieved 3 February 2014.
  23. "Future hospital: Caring for medical patients" (PDF). Royal College of Physicians. 16 September 2013. Retrieved 3 February 2014.

Further reading
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