The Doctor's Doctor: How To Become An Internist In Five Minutes

Internists are known as the doctor's doctor. The breadth of knowledge for internists is enormous. I often laugh at the computer science folks who do drivebyes on my blog and claim that one day a computer will neatly categorize all illness into neat algorithms and make me expendable. It is simply not possible. As an internist, I manage the whole body. And the evaluation and management I perform on every patient is multi tiered in its breadth and structure. I do this with every patient encounter. All day, every day. If you have five minutes, I'll show you how to do what I do. I interpret my data points across four different organizational structures for every patient, every time. Consistency, consistency, consistency.
  • By Organ System. Looking at things by organ system is the first way to conquer disease evaluation and management. Is the disease in the brain? The heart? They thyroid? The lungs? The gallbladder? The bladder? The blood vessels? The blood? The bone marrow? The skin? The neurons? The spinal chord? The colon? The eyes? The hair? The nails? The liver? Disease can affect any organ and an internist's job is to figure out which one.
  • By Category of Disease Process. Looking at things by category of disease process is another way an internist must classify the illness. Is it infectious? Is it autoimmune? Is it hormonal? Is it traumatic? Is it genetic? Is it environmental? Is it medication induced? Is it a toxin? Is it allergic? Is it iatrogenic? Is it cancerous? And within each of these categories of disease processes, the internist must ask himself which organ system the disease process is affecting. Is it allergy induced asthma or is it genetic alpha-one antitrypsin induced emphysema. Is it alcohol related cirrhosis or Wilson's disease. Is it myelodysplastic syndrome, a disease of the bone marrow, or is it medication induced pancytopenia. What is the process of the disease?
  • Is It Systemic Or Localized? Once you understand the disease process and which organ it affects, you must also know whether the problem is a localized process or a systemic process, and if it is systemic, how else does it present. So much in medicine is lost when you aren't keeping your eyes open. When you focus so strongly on one part of the body and fail to understand the rest. Some infections can be localized in an organ, like an abscess in the liver. Some infections can be systemic and involve multiple organs. Like mononucleosis. Some autoimmune diseases can affect just one organ, like multiple sclerosis and its effect on the neurons of the brain and spinal chord. Other autoimmune diseases, like lupus can span multiple organs, from kidneys and brain to heart and lungs. Lets go back to the cirrhosis example. So it wasn't alcohol related after all. It was hemochromatosis, a genetic disease of iron metabolism that can also affect your skin, joints, pancreas and brain. Is your disease process systemic or localized? Sometimes you find liver disease when your looking for arthritis. It's amazing disease doesn't operate in a cubby hole. And if your disease is a systemic process, you must always be on the look out for its systemic complications.
  • Is It Acute Or Chronic? As an internist you want to know if the problem is new or old. Has the patient had heart disease for 25 years, or was it diagnosed last week? Has the patient had diabetes before or is that blood sugar of 350 a new finding? Is that Hgb of 8.9 new or was it there three years ago? Knowing whether something is new or old means all the difference in the world in how you approach it diagnostically. What are you going to do with the information you have in front of you?
What you have here is how I break down every possible illness known to man. Every possible illness can be categorized by organ system, type of disease process, a systemic or localized process and acute or chronic nature. But we aren't done yet. This is just the disease. Full of randomized controlled trials with objective data points. What about the patient? Where do they fall into the loop? Patients don't come to your office complaining of Factor V Leiden. They don't come to your hospital complaining of systemic inflammatory response syndrome. They don't come to your office or hospital complaining of grade II esophageal varices. They come to your office complaining of a swollen leg. They come to your office with dizziness and pain when they pee. They come to your hospital vomiting blood. The goal of all physicians is to try and match the subjective complaints of the patient with the object data points. So you must add in the last component of being an internist
  • What Does The Patient Tell You? Are they pointing to one specific point in their belly and saying it hurts right here in my right lower quadrant? Or do they wave their hand over their belly and say it hurts all over? Are they even able to talk? Do they have one complaint? Or a hundred? Do their complaints make sense anatomically? Do they make sense physiologically? Is that pain that jumps from the right leg and makes a right angle turn across the abdomen into the left pinky finger real? Are their complaints believable? Are there too many complaints to believe any of them, the pan positive review of systems? Does mental illness cloud their reality? What the patient tells you can either be diagnostic of a very specific condition or more likely, a generalized constellation of complaints that could be a multitude of disease processes as described above. Great historians are wonderful. Bad historians are painful to work with.
And after the patient has talked with you, Dr Internist, it's your job to try and figure it all out, from the top of the their fro to the bottom of their big toe.
It can be very simple
  • I'm coughing, short of breath and have fever and an infiltrate on chest xray which turns out to be a simple pneumonia.
Or it can be something much more complex.
  • I'm coughing, short of breath and have fever and an infiltrate on chest xray may in fact be Wegener's granulomatosis, an autoimmune process associated with acute renal failure. It may in fact be a post obstructive infiltrate caused by large lung mass and complicated by an empyema. It may in fact be acute lung injury caused by amiodarone toxicity. It may in fact be tuberculosis. It may in fact be an infarct from a pulmonary embolism. It may be a lot of things.
It may be a lot of things. That's what you can expect from your internist. That's why you should want an internist taking care of you. That's how an internist thinks. That's how they were trained. That's how they manage patients every day of the week. That's why internists won't be replaced with computers. That's why they wont be replaced by extenders. In spite of the folks who say we just need more extenders to manage our health care system. They are not trained to do this type of critical thinking. They do not have the medical foundation or the experience to manage illness through these 4 concurrent stages of evaluation. I know this because I did not fully understand it until the end of my seven year journey to my National Board Exam, which certified my as a physician with expertise in his field of knowledge. A knowledge base you want if you ever get sick.

There you are. That's what your internist does. Every day. That's why the world needs us. Because we have the ability to do something nobody else in the world can. And that is to be the doctor's doctor.

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14 Outbursts:

  1. Ah yes, the promise of the "expert system" I remember back in the 80's we were going to put docs out of business with them. Almost 30 years later and the only people that actually use them are computer tech support systems that are read to you over long distance telephone lines by someone who doesn't actually speak the language they are trying to pronounce. We all know how well that works...


    PS, I am a computer geek of the highest order, but am aware of the limitations of what I do ;)

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  2. Hey Happy,

    I thought that pathologists were known as the "doctor's doctor".

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  3. Yup, that about sums it up. There will still be Internists to manage the hospitalized patients (Hospitalists) and you will have a lot to do because there will be no Internists in the office diagnosing early or keeping patients out of the ERs and hospitals. You think the financial crisis is big? Watch what happens when primary care is gone.

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  4. In the past I always thought of a radiologist as a doctor's doctor (ie they help the doctor interpreting studies for diagosis/treatment). The sad fact is that when I trained, we used to go down for "radiology" rounds daily. Early in practice I would call/or stop by the reading room for help regularly. However, lately my oldtime radiology collegues are retired to be replaced by ROAD lifestyle ones that appear to be irritated that I am bothering them. If I get have one more "have you looked at the report" I am going to get nasty. Before my rads collegues start whining about the increased workload, Remember, us clinical docs usually start and end days before/after you do. I really miss the old-time rad docs.
    my 2 cents.

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  5. I love this. As a hospitalist, and one cares deeply about health care delivery, I hope that I won't be replaced by an "extender." I am saddened and frustrated by the path that primary care is taking, and hope that physicians will become leaders in tranforming and guiding health care to where it needs to go.

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  6. Very well said. A good intenrist is indispensible. They save lives, they save money (as i talk about ina recent post), and are workers of the whole system. Unfortunately our value is still relatively underappreciated!

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  7. Hmmm . . . I think I remember radiologists saying the same thing about reading mammographies as you HH are saying about your oh-so-special skills . . . Yet, what did that new study say last week . . . computers do just as good job as radiologists when it comes to mammographies. . .

    The problem with doctors is not that they have bizarre,self-flattering notions of themselves (they do) but rather they influence and control regulation of healthcare (and markets thru their control of their guild and hospital monopolies) to crush technological innovations.

    Doctors, not diseases kill--and they will continue to do so unless we strip the privileges they currently enjoy from them.

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  8. Anonymous 12:19, you're right. Doctors, not diseases do kill.

    Why, just the other day I asked Diabetes to help diagnose and treat this terrible Family Medicine doctor who'd taken up residence in my left lung. It was tough, but we got our friend Ankylosing Spondylitis to help us out.

    Tomorrow we're going over to my buddy's house where some pesky EM doc is inflaming my friends appendix with a kazoo, of all things. We might need Cancer's help on this one.

    I'm sorry we were too late to save you from whatever doctor performed that lobotomy, you moronic, awful jackass.

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  9. Hit a nerve, Savage? The notion that doctors may do more harm than help (particularly internists who deal with difficult, ambiguous cases) is hardly controversial. And, that doctors are so defensive at this claims suggests a protective, narrow-mindedness.

    The fact is, Savage, that as every health care economist knows, there is no connection whatsoever between aggregate healthcare expenditures and healthcare outcomes.

    http://www.cato-unbound.org/2007/09/10/robin-hanson/cut-medicine-in-half/

    Thus, while no doubt there's successful treatments, it's reasonable to conclude that there's a lot that's just bogus or indifferent or harmful (And, what percentage of the treatments YOU prescribe Savage are evidence based?)

    Get a little humility.

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  10. Dear anonymous:
    To paint all doctors with such a broad brush is just plain wrong. There are many truly dedicated physicians out there that care deeply about the health of their patients and keep that sentiment day in and day out.

    I agree with you that spending more money does not always equate to better health care.

    Also, no disrespect but you would have more credibility if you put a name to your comments.

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  11. Day-Um, Annonymous you're on to all our tricks!! Do a Google on "Venous Air Embolism" sometime. Thats what happens when your Anesthesiologist forgets to change your IV bag cause his Stocks just tanked. And I've heard every specialty say they're the "Doctors Doctor".

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  12. Anonymous, I am not a physician.

    The only nerve you hit in me is the ridiculous hyperbole nerve, which runs parallel with my colon.

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  13. My take on internal medicine is that it is all about fluid shifts.

    You have someone in CHF, you fix it, they go home. They come back with renal insufficiency, you fix it, they go home. They come back with ascites, you fix it, they go home.

    It's the same fluid that just gets shifted from organ system to organ system.

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  14. Peter Haha, you are funny!!!!

    Dr. Brayer You post on the upcoming major disater involving the shortage of Internest's was fantastic!

    i think Internest's are amazing, for m a n y reasons and am so fortunate to have the one i do. He is just fantastic in so many ways. But with the awful life an Office Internest has to lead, it wouldn't surprise me one bit if he became a Hospitalist...i would be devestated, but who could blame him...?

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