ACP: Raising the profile of internal medicine

ACP: Raising the profile of internal medicineA guest column by the American College of Physicians, exclusive to

ACP recently launched a campaign to celebrate and increase awareness of internal medicine, the “I.M. Proud to Be an Internist” campaign. If you visit the website, you will find a summary of the campaign’s goals,  information for patients and families, links to downloadable posters for the office, and merchandise that publicizes the campaign, such as t-shirts and coffee mugs (disclosure: I was given a free t-shirt by ACP, but that did not influence my decision to write this column). There is even an accompanying video.

This is not the first such effort to raise the profile of internal medicine (remember “Doctors for Adults” in the 1990s?) and it won’t be the last, because describing internal medicine in a sound bite is no easy task. The primary target of these initiatives is the general public, which confuses internists with interns, family physicians, or general practitioners, but I would argue that other health professionals, including physicians, should pay attention to “I.M. Proud to Be an Internist.”

At the core of the campaign is a new definition of internal medicine: “Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness.”

The most important word in that definition is “specialist.” We are specialists, a point that is forgotten even by many internists, who refer to cardiologists, gastroenterologists, and rheumatologists as “specialists,” when these physicians are actually subspecialists. (If they are “specialists,” then what does that make us?)

One of my goals when I was Chair of the ACP Board of Regents was to remind my fellow internists of this at every opportunity, so I would introduce myself as an “internal medicine specialist in outpatient practice” or some variation of that, as opposed to a “generalist,” “general internist,” or “primary care physician” (or “PCP”). It took longer and involved more syllables, but it sent a message. I am a specialist.

As an internal medicine specialist, I am trained to take care of a variety of medical problems, including many common ones that are sometimes also managed by internal medicine subspecialists. For example, in a typical week, I see patients with diabetes, asthma, atrial fibrillation, gastroesophageal reflux disease, and osteoarthritis. Most of those patients do not see endocrinologists, pulmonologists, cardiologists, gastroenterologists, or rheumatologists – internal medicine subspecialists – they just see me. One would think that other health care workers, especially other internal medicine specialists, would understand that, but unfortunately, that is not the case.

Recently, one of my patients presented to the hospital with pneumonia requiring admission. He also has atrial fibrillation, which I manage with warfarin and beta blockers with adequate rate control and no symptoms from his condition. More than once, this patient was asked by nurses and hospitalists who his cardiologist was and, in at least one case, was asked why he didn’t have a cardiologist. I have patients with diabetes who are not just asked who their endocrinologist is; they’re given the impression that something is wrong because they don’t have one. I see the same happen to patients with stable coronary disease, migraine headache, and anemia. An internal medicine specialist is trained to treat patients with these conditions – a referral to a subspecialist is appropriate when additional expertise is needed, but not all patients with these conditions need a subspecialist.

To me, the most disappointing examples similar to those I just described involve internal medicine residents. If an internal medicine resident doesn’t know what an internal medicine specialist does, then who will?

One of the rewards of taking care of patients for many years is earning their loyalty and trust. So instead of asking me “why didn’t you send me to a specialist,” most of my patients’ reactions are more like “I can’t believe she suggested that” or “I don’t really need to see someone else for this, do I?” But not all practicing internists are so fortunate, and all of us have a few patients who don’t need much encouragement to add another physician to their roster.

I don’t feel threatened by this lack of knowledge of what an internal medicine specialist does, but it does frustrate me, since a basic understanding of the roles of the members of the health care team is essential to our working effectively for the benefit of our patients. I chose not to subspecialize because I enjoy the breadth and diversity that general internal medicine practice provides. My training enables me to treat patients with a wide variety of problems. At the same time I recognize the limits of my expertise and refer to internal medicine subspecialists or other specialists when necessary.

The “I.M. Proud to Be an Internist” campaign is a great effort to get the word out on the unique value of internal medicine. But patients, purchasers, and payers are not the only ones who should take notice. Providers, physician and non-physician, have much to learn as well.

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • rtpinfla

    I am IM as well as an IM subspecialist. I applaud the efforts of the ACP to raise awareness. IM really is a unique and is way underutilized but think they really ought to hire a better publicist. Putting posters in the waiting room is preaching to the choir.
    IM’s unique skill set is the ability to understand and synthesize multiple medical problems, social issues, and manage the whole patient rather than having 5 specialists managing in an often conflicting and nearly always disjointed manner. I am thinking mainly of the outpatient setting but applies to the hospitalists as well.
    Healthy patients and patients with 1-3 stable medical problems and no end organ damage don’t really need an IM. However, the patient with more than 3 diagnosis’ and/or end organ damage would benefit immensely from the unique skills set IM provides. Those patients would not need to see multiple specialists multiple times when they have one well qualified physician to handle those complex issues.
    I have always joked that the best IM slogan would be “Come see us when the damage is done” since we are best at managing those patients with multiple organ dysfunction (CAD, renal insufficiency, diabetes, couple of CVA’s). Another good slogan would be “Do you want to see seven doctors this month or just one?”
    Regardless of the slogan, IM needs to do a much better job of highlighting what we can do for the patients we are not seeing. The patients in our waiting room already know.

  • Steven Reznick

    While I applaud the article and Dr Ejenes comments, the ACP needs to really put up or shut up. Their policies over the years have been extraordinarily negative towards the practice of general internal medicine and extremely pro procedure oriented medical subspecialty medicine.
    I am not sure that I agree with rtpinfla’s comment that if you have 1-3 stable medical conditions you do not need an internal medicine specialist. Internists have been trained to be the detectives who figure complex problems out but are also well trained in prevention

    • Mengles

      Exactly. Of course this is the same person who thinks the RVU committee works fine and dandy so realize this nothing but bs.

    • rtpinfla

      Maybe a better wording would have ben “don’t necessarily need an IM”. While we are also very good at prevention, that is not what makes IM unique as a specialty. But I take your point.

  • Margalit Gur-Arie

    In addition to the historical errors mentioned by Dr. Reznick, I think there are significant shortcomings in what is planned, or advocated, for the future. Looking at the medical home model, for example, one can see an inordinate preoccupation with process and structure of primary care, whether IM or Peds or Family practice, and practically no concern with comprehensiveness of services. Is it really more important to track hundreds of referrals to sub-specialists in minute detail, than to encourage a scope of practice where fewer referrals are made? And yet, there are no brownie points for low referral numbers….

    • Steven Reznick

      Hard to do but it would be best to reward appropriate referrals not necessarily low referral numbers. Everyone has a different level of training and experience and comfort level in dealing with a problem. Practitioners I know have referred everything for subspecialty coverage for medical legal reasons or just because it was easier to pass on the problem and act as a triage station. Others , who feel comfortable evaluating and treating a problem initially are asked to refer by the patient or their family because they read that this was the correct thing to do in the New York Times health section or New York magazine. Others work up a problem until they need assistance and then ask for help. Rewarding a consistent and logical approach to care and problem solving would be best if such a review and evaluation were possible. Not sending someone for an opinion when you need help is as serious or worse than sending too many. While cost effectiveness is extraordinarily important, preventing illness or making the patient well is the primary goal.

      • Margalit Gur-Arie

        Yes, of course, I wrote that last sentence too quickly. Also I am not sure how advisable it would be to have a third party evaluate the appropriateness of one’s referrals, although this is what HMOs and ACOs probably do. Perhaps a better way would be to look at what is usually being addressed or managed in the clinic, as opposed to what is being routinely sent out. It would be interesting to see some studies along these lines….

  • Ronald A Primas

    Bravo Dr.Enjes! I have been a solo practicing board
    certified and multiply recertified internist for over 2 decades. The majority of my patients are fully aware of what an internist is thankfully. They appreciate the level of care and expertise an internist affords them. Yes, I get the occasional, “so that means you’re a GP” or “an
    intern!” or “just an internist”:), but that is rare.
    More pressing however than our viability, is our relevance.
    Over and over again, it is a constant reminder of how irrelevant people
    perceive us. Each time I admit to the hospital, my patients are automatically put on the hospitalist service. I am asked daily, “are you sure you don’t want to put your patient on our service”. Often, simple admits like phlebitis, pneumonia, etc. are put on the subspecialty or other services.Hospitals even have a term for a patient returning post discharge to their internist: it is called “leakage”!
    Also, many of our longstanding patients are going to”doc in the boxes” for their care. Even if we can accommodate them within a few short hours, they still choose to go “someplace closer who can fit them in right away”. I guess it’s just a sign of the times. Everyone wants instant gratification. I think as internists, we need to address that and emphasize the importance of having continuity of care with someone who is familiar with the patient’s entire history.
    We also need to make IM attractive to our med students. Many are going into FP because they believe that under the new healthcare system, FP’s working in clinic’s will have more of a choice moving forward. We need to address all of these issues.

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