ACP: Raising the profile of internal medicine

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

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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