Core competencies of the European internist: A discussion paper

1. Preamble 

The European Board of Internal Medicine (EBIM) was formed by the European Federation of Internal Medicine (EFIM) and the Section of Internal Medicine of the European Union of Medical Specialists in 2002. In 2004, the EBIM formed a working group to define the competencies of the internist in order to enhance the quality of internal medicine practice and to reform the education of internists across Europe. Although some variations in the practice of internists may be present in different countries, this paper will focus on the general competencies that are common to all internists in Europe.

Internists have a fundamental role in the health care systems of modern societies. This is largely due to the high prevalence of chronic and complex diseases that are associated with the lifestyle of Western societies, most of which are managed by internists or physicians who practice in a subspecialty of internal medicine. The practice of the internist ranges from medical consultation to the care of patients with multiple chronic diseases. In addition to office practice, many internists care for acutely ill patients in the hospital setting. The European Union of Medical Specialists has defined an internist as follows. “An internist is a physician trained in the scientific basis of medicine, who specialises in the assessment, diagnosis and management of general medical problems, atypical presentations, multiple problems or system disorders. The physician is skilled in the management of acute unselected medical emergencies and the management of patients in a holistic and ethical way, considering all psychological as well as medical factors for enhancing quality of life. The physician values the continuing care of all patients irrespective of the nature of the patient's complaint, and is committed to lifelong continued professional development. The physician practices clinical audit and evidence-based medicine. The physician functions in a number of roles, including clinical counselling, educating, leading and managing.” Although the practice of internists varies to some extent between European countries, provision of comprehensive medical care is the common theme. Many internists provide subspecialised care, frequently based on specific areas of interest. Which disorders are usually managed by internists or by subspecialists or by both internists and subspecialists together will, of course, vary from country to country.

In recent years, it has become recognized that knowledge and clinical skills alone do not ensure a physician's competence or performance. Concerns over reports of frequent medical errors have led to demands that physicians demonstrate adequate clinical competence and practice performance throughout their career. To meet these new challenges, organizations of physicians have placed greater emphasis on proficiency in alternative areas of professional medical practice such as communication skills, professionalism, and systems-based practice. Efforts to redesign medical education and training are already being made, shifting the focus from assessment of knowledge to multidimensional evaluation of clinical competence. Several professional organizations have defined the essential competencies of physicians. In 1999, the Accreditation Council for Graduate Medical Education in the United States defined a set of six general competencies that all residents in postgraduate specialty training programs should master [1]. These competencies have since been adopted by the American Board of Internal Medicine [2]. Similarly, the Royal College of Physicians and Surgeons of Canada has accepted a generic competency framework that originated from the CanMEDS 2000 project [3]. The development in Europe has been slower, although substantial work has already been done in some countries, like the Netherlands, where the Royal Medical Association has developed guidelines for postgraduate specialty training programs that include the definition of seven competency fields [4].

The explicit definition of the core competencies of physicians has been relatively simple in North America, where training and work practices are more or less similar. In Europe, however, the task is not as simple, especially in internal medicine, in which training and practice have traditionally varied considerably from country to country. Whilst this variation might have been acceptable in the past, this is no longer the case, as medical graduates increasingly move from country to country to both train and practice. We believe it has become urgent for European internists to define the core competencies of their specialty. These core competencies must be based on the internist's roles and the nature of the clinical problems that he or she commonly encounters. They should also reflect how the internist approaches the patient's problem.

2. The roles and abilities of the internist 

The principal role of internists is to provide medical care for adults. Certain professional attributes are required for the internist to be successful in a rapidly evolving world of medicine. As a member of a health care team, the internist has to effectively coordinate the care provided by other professionals for the benefit of the patient. Internists should also facilitate and support the participation of patients in their own care and aid them in making decisions regarding health issues. The internist needs to be an advocate on health issues for both individual patients and the community at large. He or she must be able to communicate clearly with both patients and colleagues alike. Furthermore, the internist will, in certain situations, require managerial and business skills. Finally, internists should be proficient in both teaching and scientific enquiry.

A major task of internists is the diagnosis and management of multiple medical problems that may be complex and are frequently of chronic nature. These disorders may be managed in an outpatient and/or inpatient setting, with or without the contribution of a subspecialist colleague. The internist must be able to recognize and evaluate the symptoms and signs of common diseases. The internist may also be faced with obscure symptoms or features of multisystem disease that require expert diagnostic evaluation. However, most internists will spend the majority of their time managing a relatively limited number of common medical problems.

3. Core competencies of the internist 

4. Conclusions 

This paper is a discussion document that has made an attempt to capture the essence of internal medicine in the 21st century. Despite all of the advances in science and technology, the patient–physician interaction remains the cornerstone of the practice of internal medicine. However, as a result of these advances and a rapidly evolving health care environment, we believe that the time has come for European internists to take stock of the current core competencies of their specialty and how they are likely to develop in the future. These core competencies are the foundation required for the provision of high-quality medical care everywhere, regardless of the professional traditions and organizations in different countries. In order to meet the health care needs of individual patients and society at large throughout Europe, it is important that these competencies become part of medical school and postgraduate training curricula, as well as of continuing professional development programs in all European countries. The EBIM Working Group hopes this paper will stimulate constructive discussion and thoughtful debate, and that it will be followed by a collaborative effort to develop and endorse a European consensus.