Internal medicine

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Internal medicine is the medical specialty concerned with the diagnosis and nonsurgical treatment of unusual or serious diseases, especially where there is difficulty in diagnosis or management. In North America, specialists in internal medicine are commonly called internists. Elsewhere, especially in Commonwealth nations, such specialists are often called physicians, in the older, narrow sense of the word (in North America, physician now commonly applies to any medical practitioner).

Because their patients are often seriously ill or require complex investigations, internists do much of their work in hospitals. Many are in consultant practice, only seeing patients referred by other medical practitioners, to help solve complex problems. Because of this tradition, internists have sometimes been described as the "doctor's doctor".

Formerly, many internists were not subspecialized (general physicians in Commonwealth parlance), and would see any complex nonsurgical problem; this style of practice has become much less common.

In modern urban practice, most internists are subspecialists: that is, they generally limit their medical practice to problems of one organ system or to one particular area of medical knowledge. For example, gastroenterologists and neurologists specialize respectively in diseases of the gut and the nervous systems. Specialist or consultant pediatricians and geriatricians could also be described as internists who have subspecialized by the age of their patient, rather than by organ system.

Internists have a lengthy clinical and scientific training in their areas of medical interest, and have special expertise in the use of drugs or other medical therapies (as opposed to surgery). While the name "internal medicine" may suggest that internists only treat problems of "internal" organs, this is not the case. Internists are trained to treat patients as whole people, not mere organ systems.

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[edit] Definition of an internist

Internists hold a medical degree. They are not to be confused with "medical interns," who are either physicians in their first year of residency training (in countries like the USA), or last-year medical students (in countries like Colombia). Although Internists may act as primary care physicians, they are not "family physicians," "family practitioners," or "general practitioners" (whose training in certain countries includes the medical care of children, and may include surgery, obstetrics and pediatrics). General Internists practice medicine from a primary care perspective but they can treat and manage many ailments and are usually the most adept at treating a broad range of diseases affecting adults.

Internal Medicine sub-specialists may also practice general internal medicine, but can focus their practice on their particular subspecialty like cardiology or pulmonology after completing a fellowship. (Additional training of 2-3 years)

In the USA, adult primary care is usually provided by either family practice or general internal medicine physicians. The primary care of adolescents is provided by family practice, internists and pediatricians. The primary care of children and infants is provided by Family Practice or Pediatricians, thus, there is overlap. These physicians can have either an MD,DO, MBBS, MBChB, BMBS, BMed, MBBChir, Degree.

[edit] Caring for the whole patient

Internists are trained to solve puzzling diagnostic problems and handle severe chronic illnesses and situations where several different illnesses may strike at the same time. They also bring to patients an understanding of preventive medicine, men's and women's health, substance abuse, mental health, as well as effective treatment of common problems of the eyes, ears, skin, nervous system and reproductive organs. Most older adults in the United States see an internist as their primary physician.

[edit] Education and Training of Internists

Main article: Medical education

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

First, they must receive the "entry-level" education required of any medical practitioner in the relevant jurisdiction. In all developed countries, entry-level medical education programs are tertiary-level courses, undertaken at a medical school attached to a university. Depending on jurisdiction and university, entry may follow directly from secondary school or require pre-requisite undergraduate education. The former commonly take five or six years to complete. Programs that require previous undergraduate education (typically a three or four year degree, often in Science) are usually four or five years in length. Hence, gaining a basic medical degree may typically take from five to 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 full licensure, or registration, is granted, typically one or two years. This period may be referred to as "internship" or "conditional registration". Then, internists require specialist training in internal medicine or one of its subspecialities. In North America, this postgraduate training is often referred to as residency training; in Commonwealth countries, such trainees are often called registrars.

Training in medical specialties typically takes from three to six years, and sometimes more, depending on specialty and jurisdiction. Any medical practitioner who completes specialist training in internal medicine (or in one of its sub-specialties) is an internist, or a specialist physician in the older, narrower sense. In some jurisdictions, training in internal medicine is begun immediately following completion of entry-level training, or even before. In other jurisdictions, junior medical doctors must undertake generalist (un-streamed) training for one or more years before commencing specialization. Hence, depending on jurisdiction, an internist (specialist physician) often does not achieve recognition as a specialist until twelve or more years after commencing basic medical training — five to eight years at university to obtain a basic medical qualification, and up to another six years to become a specialist.

[edit] Subspecialties of internal medicine

Internists can choose to focus their practice on general internal medicine, or may take additional training to "subspecialize" in one of 13 areas of internal medicine, generally organized by organ system. Cardiologists, for example, are doctors of internal medicine who subspecialize in diseases of the heart. The training an internist receives to subspecialize in a particular medical area is both broad and deep. Subspecialty training (often called a "fellowship") usually requires an additional one to three years beyond the standard three year general internal medicine residency. (Residencies come after a student has graduated from medical school.)

In the United States, there are two organizations responsible for certification of subspecialists within the field, the American Board of Internal Medicine, and the American Osteopathic Board of Internal Medicine.

The following are the subspecialties recognized by the American Board of Internal Medicine[1].

The ABIM also recognizes additional qualifications in the following areas

Internists may also specialize in allergy and immunology. The American Board of Allergy, Asthma, and Immunology is a conjoint board between internal medicine and pediatrics.

The American College of Osteopathic Internists recognizes the following subspecialties. [2]

[edit] Principles of diagnosis

The main tools of the doctors are the medical history and the physical examination, but this holds particularly true for internal medicine. Subtle descriptions of disease (e.g. cyclic shallow and deep breathing, as in Cheyne-Stokes's respiration, or persistently deep breathing as in Kussmaul's) or physical signs (e.g. clubbing in many internal diseases) are important tools in guiding the diagnostic process. In the medical history, the "Review of Systems" serves to pick up symptoms of disease that a patient might not normally have mentioned, and the physical examination typically follows a structured fashion.

At this stage, a doctor is generally able to generate a differential diagnosis, or a list of possible diagnoses that can explain the constellation of signs and symptoms. Occam's razor dictates that, when possible, all symptoms should be presumed to be manifestations of the same disease process, but often multiple problems are identified.

In order to "narrow down" the differential diagnosis, blood tests and medical imaging are used. They can also serve screening purposes, e.g. to identify anemia in patients with unrelated complaints. Commonly performed screening tests, especially in older patients, are an X-ray of the chest, a full blood count, basic electrolytes, renal function and blood urea nitrogen.

At this stage, the physician will often have already arrived at a diagnosis, or maximally a list of a few items. Specific tests for the presumed disease are often required, such as a biopsy for cancer, microbiological culture etc.

[edit] Treatment

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

Pulmonology: Bronchoscopy

[edit] See also

[edit] External links

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