Why family medicine and internal medicine should not merge

Recently, I had a discussion with a prominent academic family physician.  I had last seen him 37 years ago when he was getting ready to graduate from medical school and I was a new medical student.

We had a wonderful discussion and agreed to disagree about merging primary care.   Long time readers know that I dislike the term for the tasks that outpatient internists do.  Most of the push for merger comes from family medicine.

I sit in an unusual situation – I make rounds at 2 hospitals, one with an internal medicine residency program and the other with a family medicine residency program.  I work closely with family physicians and of course I am an internist.

New internists are avoiding primary care assiduously.  Internal medicine residency provides abundant options for its graduates.  We can understand the forces driving subspecialty choice through simple observation over the years.

As my colleague admitted, in Great Britain internists fill the hospitalist role – they do not do outpatient medicine.  Internal medicine’s prototypical educator, Sir William Osler, worked primarily in the hospital.

Now I could agree with family medicine providing more primary care options, including allowing emphasis in adult medicine, or pediatrics, or women’s health, or sports medicine, or geriatrics.  Why should internal medicine change its training?  Do we have any evidence that our training is substandard?  If an internal medicine graduate wants to do outpatient medicine, he or she will have a learning curve.  Having climbed that curve earlier in my career, I believe that any well trained internist who wants to focus on outpatient medicine can succeed in incorporating the knowledge and skills needed for outpatient medicine.

When my obstetrics colleagues hire a new graduate, they have to help them learn how to practice.  Surgeons face the same hurdle.  Residency training provides us knowledge and skills, but we should not stop learning when residency ends.  We all must develop new knowledge and skills the depend on the particular position we are filling.

Family medicine training provides a broad overview of medicine, pediatrics, ob-gyn, sports medicine, psychiatry, etc.  Internal medicine training provides depth in adult medicine.  While family medicine and internal medicine represent overlapping Venn diagrams, they have major and important differences.  They need not merge.  We should learn from each other, but continue to celebrate our differences.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • Edward L Terrell, M.D.

    I have thoroughly enjoyed reading (and learning from) the posts from KevinMD.com. Very timely and very much a pleasure to read. I look forward to his posts on a regular basis.

  • C Dahlin

    I agree with Dr Centor. I am in a group of two internists and one FP; we bring different skill sets to the table. The two specialties are not the same, and should not merge.

  • solo dr

    My local call pool lumps IM and FM into the same call pool. Interestingly during general call the peds patients are sent to me but not to the IM docs. The IM docs don’t seem to know how to care for the kid with OM or mono.
    Most IM docs won’t see any patients under either 16 or 18, depending on the group.
    My patient range is from peds through over 100 y.o. Most IM docs in town seem to focus on geriatric and middle aged patients. I like the mixture of age groups and varieties in my FM practice.
    Other articles talk about merging all primary care, IM, FP, peds, and ob/gyn. The only advantage of this, if each area could keep some autonomy, would be if we could bargain to have better office visit fee schedules. Unfortunately the government won’t let us group together to have bargaining power against the insurance companies.
    Currently there would be no advantage of lumping the primary care area together.

  • C Dahlin

    In our call group, the FP’s (2/5) are not as experienced with acute care, ICU, and severe multifactorial illnesses. We consult with each other in the hallway a lot. As I said, it’s a different skill set. It’s complementary, not not the same,

  • http://bittersweetmedicine.com DrLemmon

    Maybe there should be no more Family Medicine. Maybe there should only be IM, Peds and Ob- Gyn. IM could of course learn some basic Peds and Gyn or at least some Gyn. No need to refer everything out. Family medicine as it was conceived is becoming obsolete. I am not going to list all the reasons here; it has been discussed before. It is heartbreaking, but true. If Family Medicine went away, that would be the same as a merger as there would be no other option for a primary care physician.

  • ErnieG

    It’s not clear (in this post) why IM and FM should be separate (other than giving IM graduates the option to specialize). There is a subtle admission in the post that IM graduates are not trained for general outpatient medicine, that somehow the IM trainee will learn this on the job. But isn’t that what residency is for? The major and important differences that should be celebrated seem to dissolve with the on the job post residency training. I think the argument, as presented by Centor is weak.

  • jsmith

    I’m an FP who used to work in an adult medicine dept with IMs and FPs. I too am gainst the merger. I do more hands on stuff and they do more mulltifactorial stuff. Our training makes up better for rural medicine and ER, and peds of course. Theirs makes them better for the hospital. A group with both specialties can work well.

  • Sandra

    It would be nice to nail down what the differences are between IM and FP so we all have the same expectations.

  • http://www.meyersmedmal.com Jivanmeyers

    Dr Lemmon, internal medicine is on the eve of extinction. University Center hospitals in my community are buying up all the internal medicine practices and treating internists and family practitioners as if there was no difference. Any internist may choose to have an out patient practice. An internist is a specialist in adult medicine. Internal medicine provides the soul of differential diagnosis. Now family practitioners can become board-certified as a hospitalist. This makes a mockery of internal medicine and is driven by hospitals trying to increase profit margins without regard to patient welfare.

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