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What is internal medicine?

      The European Journal of Internal Medicine's new policy of asking authors to submit their papers to a sub-speciality editor has highlighted a perennial problem that has bedevilled our speciality — what is internal medicine?
      A precise definition of internal medicine remains elusive. The term was derived from “Innere Medizin” that developed in Germany and Austria in the early 1880s when physicians began to practice clinical medicine based on the latest advances in physiology, bacteriology and pathology [
      • Beeson P.B.
      • Maulitz R.C.
      Grand rounds: one hundred years of internal medicine.
      ]. The primary role of the internist was as diagnostician who was consulted to advise on the most difficult cases. However, over the last 40 years internal medicine has fragmented into several sub-specialities and advances in laboratory and imaging technology have considerably reduced its role in diagnosis. What is left?
      Evidence-based medicine suggests that eventually it will be possible for all medical practice to be performed perfectly under conditions of complete certainty — that once the exact diagnosis is made the appropriate expert will provide the correct treatment and the best possible results will be obtained. The assumption is that complete knowledge results in certainty and perfection. However, like any biological system, medicine is not like that. As Nardi et al. point out in their recent excellent review only a small amount of medical practice concerns known or knowable phenomenon, and most medical presentations are complex and sometimes completely chaotic [
      • Nardi R.
      • Scanelli G.
      • Corrao S.
      • Iori I.
      • Mathieu G.
      • Amatrian R.C.
      Co-morbidity does not reflect complexity in internal medicine patients.
      ]. This is particularly true of internal medicine practice, which often deals with elderly patients with multiple co-morbid conditions, or young patients not easily classified in a single sub-speciality that may have multiple medical and psychosocial problems.
      Most patients, especially those who die, have several co-morbid conditions and may not be best cared for by a single mono-specialist. The need for the modern internist to manage patients with several simultaneous co-morbid conditions cannot be overemphasised. In an era of increasing demand that inevitably results in resource limitation, it is more important than ever to use diagnostic and therapeutic technology prudently. Sub-speciality medicine, by its nature, is constricted to a limited number of diagnoses. In contrast, by managing an entire range and combination of conditions, the general physician can deliver less expensive and better care [
      • Wachter R.M.
      • Katz P.
      • Showstack J.
      • et al.
      Reorganising an academic medical service: impact on cost, quality, patient satisfaction, and education.
      ].
      In addition to the traditional clinical competencies shared with all other physicians the internists have a unique competence in dealing with patients with multiple illnesses and co-morbid conditions. The internists should be the master of complexity and co-ordinator of chaos. In particular they must be familiar with the care of the elderly, stroke and disabled patients, other vulnerable populations and palliative care. The internal medicine specialists should also be skilled in dealing with difficult patients or relatives, and have good communication and management skills. The internists must also be able to convey an accurate prognosis along with the risks and benefits of any available investigations or therapy, so that their patients can come to a wise decision as to how they wish to be managed. Therefore, the internists should be familiar with decision theory, cost-benefit, cost-effectiveness and decision analyses. They should also be familiar with the use of predictive and other decision support computer models. In order to fulfil their pivotal role in health care the internist requires several health systems skills. These include good interpersonal skills and a team approach to multi-disciplinary care, knowledge of information technology and expertise in the efficient use and management of the resources so that their patients get the best care possible as quickly as possible.
      Therefore, if you are about to submit an article to the internal medicine section of EJIM first check if it deals with any of the following:
      • 1.
        Processes of care for the management of multiple simultaneous illnesses, complexity and chaos,
      • 2.
        Advising patients on their prognosis and therapeutic options,
      • 3.
        Communication and management skills,
      • 4.
        Cost-effectiveness and other health system skills.

      References

        • Beeson P.B.
        • Maulitz R.C.
        Grand rounds: one hundred years of internal medicine.
        in: Maulitz R.C. Long D.C. The Inner History of Internal Medicine. University of Pennsylvania Press, Philadelphia1988: 15-54
        • Nardi R.
        • Scanelli G.
        • Corrao S.
        • Iori I.
        • Mathieu G.
        • Amatrian R.C.
        Co-morbidity does not reflect complexity in internal medicine patients.
        Eur J Int Med. 2007; 18: 359-368
        • Wachter R.M.
        • Katz P.
        • Showstack J.
        • et al.
        Reorganising an academic medical service: impact on cost, quality, patient satisfaction, and education.
        J Am Med Assoc. 1998; 279: 1560-1565