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Internal medicine is a specialty that is focused, as the name indicates, on the inside of the body and on the organs.
The overarching discipline has led to the creation, over the past three decades, of multiple sub-fields, in cardiology, rheumatology, nephrology, endocrinology, gastroenterology, pulmonology, infectious diseases, immunology, oncology, angiology, hematology, bone diseases and dermatology.
These sub-fields have become specialties in their own right over a number of years and have obtained the same status as internal medicine itself, which, in order to affirm its identity, is often seen as falling under the umbrella of “general” medicine.
Therefore, does this mean that internal medicine is the sum of cardiology, rheumatology, nephrology, etc.?
If this were the case, there would no longer be any internists, since no sensible physician would be able to claim such vast and in-depth knowledge across all these fields.
Consequently, general internal medicine covers most non-surgical organic diseases in adults... until the problem becomes too acute, too severe or too complicated for it to be treated by the general internist alone.
Does this mean that the general internist only plays an initial diagnostic role?
No, certainly not, since in addition to this crucial triage role, the general internist is still responsible for combining the opinions of the specialists in the context of the overall patient’s problems.
Indeed, as the patient becomes older, he/she presents with more and more simultaneous diseases (”comorbidities”) and for example an anticoagulant prescribed by the cardiologist could do more harm than good to a patient with a history of digestive problems, and similarly for an antihypertensive prescribed by a nephrologist to a patient with critical arterial insufficiency of the lower extremities or severe carotid artery stenosis
Besides this “combining” role, the internist is also, most often, responsible for locating an acute problem over the long-term.
The approach of the general internist is, therefore, not only a holistic one, but also a longitudinal one.
The role of the specialist internist is more oriented towards acute problems and technical issues, and such a specialist would not be able to master his/her own field of expertise and also that of his/her internist colleagues, both general internists and specialist internists specializing in other fields.
The specialist provides the latest knowledge of his/her area of specialty to help the patient, and at university centers, he/she is capable of developing sophisticated research programs, both clinically and/or laboratory oriented, which will make it possible to combine this knowledge via practical translational medicine.
This helps to create cutting-edge university centers where it is possible to recruit and treat patients who come from far away, attracted by university hospital centers that have been created for these purposes.
The internal medicine specialist not only responds to the generalist and to the internist, but also to other surgical or organ specialties.
He/she sees patients hospitalized in all the hospital divisions, and also in outpatient consultations where patients are referred by his/her colleagues.
He/she can follow up patients, using new techniques or treatments, over the long-term, when they require regular follow-up (for example, dialysis, regular transfusions, new and complex oncology treatments, rheumatology, infectious diseases, etc.).
Therefore, the specialist has multiple tasks, since he/she must develop cutting-edge research programs, obtain funding, teach new students and train new specialists, while treating his/her own patients.
The combination of these two approaches should lead, to the patient’s benefit, to collaborative care, during which generalist internists and specialist internists will debate and argue in a partnership of equals, in the context of an increasingly evidence-based approach to medicine.
Generalists often reproach specialists for not looking at the big picture.
Specialists think that generalists, because they are focused on the big picture, neglect specific disease issues.
These days however, the two have understood that there is no wrong perspective and that looking alternatively at the big picture and at the small detail makes it possible to take into account different and complementary perspectives!
From this symbiosis, a better future for internal medicine and its specialties is born.
The great strength of a university hospital is being able to bring together, at a single site, either in an outpatient setting or at the patient’s bedside, all of the expertise of the specialists, in order to provide the most sophisticated care, as well as research into the conditions of our patients.