Reform plan should encourage training of more internists

No matter what one's political viewpoint, health care reform is coming. It may not be the sweeping revision that the president wanted, but even in a scaled back version health reform will change things.

Among the most anticipated changes are those intended to restore primary care medicine. Over the years, primary care, particularly internal medicine, has declined as younger physicians choose higher paying sub-specialties. This has created an imbalance in which some communities have more sub-specialists than primary care physicians. The impact of this imbalance, higher costs and lack of access, are obvious. Reform must encourage careers in primary care.

There are three primary care disciplines; family practice, internal medicine and pediatrics. Pediatricians obviously take care of children, although there is overlap with family practice. Pediatricians with more specialized training care for children with complex and unusual problems. Although there is some overlap with family practice, because of their specialized training, internal medicine physicians care for adults with more complex and unusual problems.

Everyone admires the wide scope of family practice. From infants to seniors, family physicians are often the first contact for many patients. Less familiar to Idahoans however is the discipline of internal medicine. This lack of familiarity is due to Idaho not having its own internal medicine residency program. The University of Washington does have a wonderful internal medicine training program in which some residents spend their second year at the Boise VA hospital. Compared to family practice however, internal medicine has a much lower profile in Idaho.

What exactly is internal medicine? According to the American College of Physicians, the term comes from the German, innere medizin. For most of the 20th century, internal medicine was among the most prestigious of specialties and competition for residency training positions was intense. Today, many internal medicine programs go unfilled while the nation is severely undersupplied with internists.

Doctors of internal medicine care for adults only. At least three of their seven years of training are dedicated to learning how to prevent, diagnose and treat diseases that affect adults. Internists are referred to as the "doctor's doctor," because they act as consultants to help solve puzzling diagnostic problems. (But don't mistake them with "interns," who are doctors in their first year of residency training.) Although internists may act as primary care physicians, they are not family physicians, family practitioners or general practitioners, whose training is not solely concentrated on adults and includes surgery, obstetrics and pediatrics.

Internists are diagnosticians, uniquely prepared by their training to diagnose puzzling ailments. With training that is general enough to render adult primary care yet specialized enough to solve medical mysteries and manage the critically ill, internists fill the gap between family practice and the sub-specialties.

A common misconception is that internists are geriatricians. Like family physicians, internists provide geriatric care, but it is not the focus of internal medicine. Some internists choose to provide inpatient care exclusively as "hospitalists" while others limit their practices to the office. A few provide both ambulatory and inpatient care.

If health reform is to be successful, it must restore the attractiveness of internal medicine. Whether accomplished by supporting the "medical home model" or other mechanisms, the nation's health will be better served by an adequate number of internists. No primary care discipline is in shorter supply.

By virtue of their unique training and expertise, internists fill a vital public health need as adult primary care physicians and consummate diagnosticians.

Michael A. Patmas, M.D., FACP, is an internal medicine physician and Fellow of the American College of Physicians.