American internal medicine in the 21st century

Abstract

American internal medicine suffers a confusion of identity as we enter the 21st century. The subspecialties prosper, although unevenly, and retain varying degrees of connection to their internal medicine roots. General internal medicine, identified with primary care since the 1970s, retains an affinity for its traditional consultant‐generalist ideal even as primary care further displaces that ideal. We discuss the origins and importance of the consultant‐generalist ideal of internal medicine as exemplified by Osler, and its continued appeal in spite of the predominant role played by clinical science and accompanying subspecialism in determining the academic leadership of American internal medicine since the 1920s. Organizing departmental clinical work along subspecialty lines diminished the importance of the consultant‐generalist ideal in academic departments of medicine after 1950. General internists, when they joined the divisions of general internal medicine that appeared in departments of medicine in the 1970s, could sometimes emulate Osler in practicing a general medicine of complexity, but often found themselves in a more limited role doing primary care. As we enter the 21st century, managed care threatens what remains of the Oslerian ideal, both in departments of medicine and in clinical practice. Twenty‐first century American internists will have to adjust their conditions of work should they continue to aspire to practice Oslerian internal medicine.

The Laryngology Hospitalist

“…[1][2][3][4][5][6] This trend is based on the premise that concentrating on one arena improves the expertise of that practitioner and results in better care. In this context, a physician is either a hospitalist or an office practitioner.…”

“…One extension of this premise is that the traditional combined office and hospital practice can make for a clinician who is doing neither as well as possible because both demand substantial amounts of concentrated time and effort. Although there are controversies regarding this trend, [2][3][4][5][6][7][8] most studies show that there are significant decrements in length of stay and total cost, as well as a reduced tendency to obtain subspecialist consultation when a hospitalist is caring for inpatients. 1,[4][5][6][7][8][9][10] Concerns about the disruption of the patient-doctor relationship have been voiced but do not seem to be particularly meaningful.…”

Internal Medicine Training in the 21st Century

“…There was no better way, medical educators held, of conveying to trainees the kind of practical acquaintance with disease necessary to competent practice than by having them care for hospital patients under supervision. 8,10 The conditions of medical work for medical graduates were generally far removed from the hospital, but that did not lessen its appeal as a place for them to hone their clinical acumen. Thus, the notion that "training should resemble practice" would have sounded odd to Osler and his forbears.…”

“…8 Such internists are acquainted, both intellectually and concretely, with the spectrum of adult nonsurgical disease, can intelligently grapple with its variability, and are determined to do so from compassion for its sufferers. Our object in what follows is to present a case for the continued relevance of the traditional ideal and to set out the broader lines along which reform of training ought to proceed to produce internists for the 21st century.…”

Facilitating Collaboration Among Academic Generalist Disciplines: A Call to Action

“…18 In contrast, academic general internal medicine began to fl ourish in the 1970s within departments of medicine in response to federal grants for primary care education of internists and the increased availability of federal and foundation resources for health services research. 19,20 As each of the primary care disciplines emerged, their discipline-specifi c professional organizations invested considerable time and resources in establishing unique identities. The 3 academic generalist disciplines thus maintain largely separate professional organizations and research meetings, and there is no prominent generalist research journal to stimulate and support scholarly conversation or joint advocacy efforts.…”