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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