Internal medicine in Europe: How to cope with the future?

An official EFIM strategy document
Published:April 12, 2010DOI:


      Evolving from reductonism to holism, is there a future for internal medicine in Europe?

      Health reform discussions revolve around how best to achieve the goals of improving quality, increasing the access to care, and costs containment. However, in the current health reform debate, little attention is paid to how medicine is currently taught and practiced. Internal medicine does appreciate that the fundamental tenets of health arise from understanding the interaction among genomics, the external environment, and behaviour. Modern medicine often neglects this comprehensive model and treats disease in isolation, without taking into account the dynamic, integrative systems in the human body. Internal medicine can revive the essential approach in medical education and practice in looking toward “systems medicine”, which incorporates the complex biochemical, physiological, and environmental interactions that sustain humans. A holistic approach to medicine benefits patients and society, taking into consideration the ethical, socio-legal, and economic implications. Internal medicine recognizes the changing needs of a modern, health-conscious consumer. It promises greater precision in diagnosis, opportunity for earlier intervention, risk-based prevention, individualization of care, and optimization of the patient–clinician interface. This includes greater orchestration of patients, physicians and research teams, as well as an even greater demand for fully informed consent in which internists play a pivotal role.

      1. The definition and mission statement of internal medicine

      Internal medicine is the core medical discipline that is responsible for the care of adults with one or more complex, acute, or chronic illnesses, both in the hospital and in the community. It is patient-centred, scientifically based and committed to ethical, scientific and holistic principles of care.
      Internal medicine, a clinical and a scientific discipline, creates and promotes medical knowledge, methods and clinical abilities. It analyzes the findings of other medical specialties and integrates them into strategies for diagnosis, treatment and care for the individual patient. Specific fields of interests include problems caused by polymorbidity, patients with difficult and complex diagnoses as well as preventive, acute, chronic and palliative care. Internists are able to translate their knowledge into patient care. Internists cope with the challenge of developing standards, decision-making, quality improvement and patient safety tools, and integrated health care delivery systems.

      2. The essentials of internal medicine

      2.1 Patient care

      Internists are competent personal physicians who can take into consideration all of a patient's health problems, however complex they may be. Demography shows us that in European countries we will be confronted more and more with patients who suffer from multiple health problems and who need coordinated care.
      Internal medicine deals with the whole spectrum of care (following a description of the Institute of Medicine): preventive care (“staying healthy”), acute care (“getting better”), chronic care (“living with illness”), and palliative care (“coping with the end of life”). If several specialties or services are involved in the management of a patient, internal medicine is the medical specialty that has the task of establishing a strategy to coordinate medical care. In many countries internal medicine works across both the in-patient, out-patient, and community-based services and supports an optimal cooperation between hospital and primary care.

      2.2 Medical knowledge

      Internists are able to update and critically analyze new medical information. They understand the relevant scientific background and pathophysiology of the diseases they commonly manage and they are able to apply this knowledge to clinical conundrums. The internists contribute to the further development of professional scientific knowledge. Internists give high priority to their personal continuing education and they contribute with enthusiasm to the teaching of students, general doctors in training, colleagues, other healthcare professionals, patients and the public.

      2.3 Communication skills

      Internists recognize the critical importance of information obtained by a full history taking and a thorough physical examination. These are essential for establishing good rapport with their patients. They ensure that important medical information is discussed with patients and their relatives. Internists document and report patient data in detail. They also need to communicate clearly with colleagues, and other healthcare professionals, with hospital administrators and healthcare authorities, also with insurers, politicians, journalists, interested groups and the public.

      2.4 Professionalism

      Internists adopt the principles of professional behaviour as outlined by the Charter on Medical Professionalism issued jointly by the European Federation of Internal Medicine, the American College of Physicians, and the American Board of Internal Medicine. They serve the interests of their patient with altruism, empathy, and confidentiality. They respect the autonomy of patients and help to empower them to make informed decisions about their treatment. Internists are aware of their responsibility towards society. If this responsibility leads to conflicts in decision-making they endeavour to find evidence-based solutions. Internists are committed to lifelong learning and maintenance of skills necessary for the provision of quality care. They are also committed to the promotion and critical assessment of new medical knowledge, and to the implementation of scientific information and technology. They prioritize patient safety, improve the quality of care and diminish barriers to its unavailability.

      2.5 Academic activities

      Internists are committed to teaching and imparting their philosophy to medical students and postgraduate trainees. They assume a central role in the organization and advancement of education in medical schools, hospitals, and clinics. Internists are engaged in basic and clinical scientific research. They are in the forefront of translational research and its application to medical care.

      2.6 Organization and leadership

      Internists are well versed in the unique features of the integrated nature of their profession that requires a multidisciplinary approach and collaborative teamwork. The internist's wide spectrum of knowledge and skills make them best suited for leadership in the application of evidence-based and cost-effective strategies dealing with the prevention, diagnosis, and treatment of complex medical conditions.

      3. Internal medicine in Europe's healthcare systems: strategic aspects

      3.1 Integrated patient care

      Internists assume responsibility for the comprehensive medical care of all patients who need such an approach. As patient-centred physicians, internists assure a scientific, efficient and compassionate use of diagnostic and therapeutic strategies, adapted to the special needs, co-morbidities and preferences of the individual patient. Internists are specially qualified to guarantee quality medical care for patients with a combination of health problems, multi-organ and systemic diseases and undetermined health problems. They are the best to coordinate the care of patients with polymorbidity. Today most medical care relies on teamwork. Internists have good skills in leading and coordinating interdisciplinary teams. The challenge is to understand the multi-component healthcare system and to make it work synergistically in order to ensure the best outcome for their patients.

      3.2 Hospital based internal medicine

      The internist plays a central role in the hospital, being the coordinator of interdisciplinary diagnostic and therapeutic care. A well structured system of coordination and counselling by internal medicine has to be maintained or established in clinical medicine. This will increase quality of care and improve cost effectiveness of medical care in general. Similar beneficial effects can be expected by intensifying the cooperation between hospitals and out-patient/community providers. Such an approach will guarantee continuum of care for each patient. Internal medicine must have a leading role regarding all elements of interdisciplinary cooperation in hospital based patient care.

      3.3 Society and internal medicine

      In an aging population the number of people with chronic diseases is steadily increasing. This underlines the need for care coordination in these patients. Better coordination will have a positive impact on healthcare quality, on access to medicine, on the rational use of the resources and on providing cost-effective care. The internists are the best specialists to coordinate patient-centred care. They act as leaders of disease management programmes as well as providers of high quality healthcare for many of today's complex disease-related problems. A central role of the internist results in crucial advantages: a high patient-population satisfaction, optimal diagnostic and therapeutic procedures, and cost effectiveness.

      4. Concluding remarks

      European countries need integrated healthcare systems which allow efficient coordination of the various medical specialties and their ever growing diagnostic and therapeutic armamentarium. Medical care has to be optimized, not maximized. Internists are patient-centred specialists, who can fulfil this task. As generalists they have a broad knowledge of all aspects of medicine for adults, which put them in the lead to provide and coordinate medical care. Therefore, internal medicine is a cornerstone of every national health care system.