Internal Medicine

Dr Bob posts on DB's Medical Rants an interesting reference to his paper in Journal of General Internal Medicine.   Family physicians feel your pain, man …  and I agree with you that there remains a place for General Internal Medicine … but … here's what may be an odd concept:  the General Internist as specialist in complex adult medicine .. just as the pediatrician could be positioned as a specialist in complex pediatric medicine. 

Ever Since Family Medicine displaced "General Practice"  many years ago – the identity of the "other" generalists (peds and IM) has certainly been threatened.  Yes, yes … this isn't the message of Dr Centor's paper … he seems to be more concerned with pressure from the right — the specialists.  But I would argue that there exists some pressure from the left (FP) as well.

It is not uncommon that I call an Internist friend to ask for advice in a situation that involves a very complex adult problem.  Why?  Because in some cases, the training of an Internist simply prepares them better for handling such situations.    A good generalist knows the boundaries of his/her skill — and while most family physicians are capable of providing excellent care to children, adults, the elderly, and pregnant women — there are some situations in which we are better off having the help of someone who specializes.  "You are worth it" I tell my hesitant patients.   They sometimes seem to wish I could do everything for them.  I can't.  This is why we have specialists. 

Yet with their identities as "general adult medicine" physicians — there is no good method for me to refer a patient to an Internist for consultation.  Since they are  primary care physicians – there is no "referring/consulting" physician relationship between Family Physicians and Internists (or Pediatricians) .. but I think that such an arrangement would be beneficial for all. 

The "other" generalists may build a better understanding of what we do (many practicing internists and pediatricians didn't do a family medicine rotation in medical school) … and we may learn not to be so threatened by them. 

Our Mantra seems to be "we provide the same care as they do."  Which is accurate in many ways … and of course .. may be innacurate too .. since I would argue that a family physician may provide better care in many ways than an internist or pediatrician – especially for a family.  

But the point is that if these physicians could re-frame their identities as specialists in complex adult medicine – no longer would they be positioned as competition for family physicians, but as an available, supportive adjunct to comprehensive, coordinated care.

Last week, a patient transferred out of my practice.  She had complex problems that I frankly told her I didn't understand.    She asked for the name of another physician who might be helpful, and I suggested an Internist colleague who works across town.  Bottom line:  our Internist pal figured it out.  Something rare and complicated and I hadn't even thought about it.  But she did … ordered the right tests,  and I'm happy about that … but now the relationship with my patient is severed .. and .. yes .. my ego is bruised a bit. 

Had I referred the patient to a rheumatologist or cardiologist etc etc … I wouldn't be severing the relationship with my patient — nor would my ego be bruised by such a situation.  Indeed, assistance with the diagnosis and/or management of a complex problem is the purpose of such a referral. 

Hmm … so, Dr. Bob (is that what DB stands for?) … how would this work?  Referrals to the Internist …  why not?