What Is An Internist? You Have No Idea, Do You.

I often get asked the question, "What is a hospitalist?" when patients and families have no idea who I am.  Sometimes I introduce myself as an internist who specializes in hospital based medicine.  Which then forces some people to ask me "What is an internist?"

As an internist, I have chosen a field that has failed to identify itself  by the the name it has taken on.   Internist.  What does that mean?  When I was a medical student, I had no idea what an internist did.  I remembered thinking, "Why are these doctors called internists?"

On a plane trip last year I sat next to a lady who had no idea of what an internist did.  Unfortunately, her lack of understanding is probably representative of the majority in this country.  At first she thought internists were interns.   Interns are medical doctors who have completed medical school and have begun their intern  year of residency training, that grueling year that separates doctors from all other providers of medical care.  Intern programs generally exist for internal medicine, general surgery, pediatrics and family medicine.  All other training programs and subspecialties begin with an intern who has completed one year in one of these fields.

After explaining to this lady that internists are not interns, she then thought internists only took care of the belly area.  She pointed to her interns and explained her belief that internists did surgery on the innards.  I can understand that misconception as well.  When one thinks of internal, they think of their gut.  And the lay public's experience with gut problems is often a appendectomy or gallbladder surgery. 
Internists do take care of the vast majority of conditions that affect the gut.   But they don't perform surgery on the belly.    

Internists have an identity crises.  They are often lumped in with other primary care providers by a public who lacks an understanding of what it is we have been trained to do.  I'm sure even my family questioned what I do before educating themselves.  Internists are doctors of adult medicine.  We manage the vast majority of all acute and chronic medical conditions, both stable and unstable, and for 90% or more of the adult population, we have the skills to manage these conditions independently without necessary referral for subspecialty evaluation. 

Given the current unforgiving legal climate  and the economic necessities of our fee free for service system, internists have, in many cases become nothing more than triage artists, playing overpaid captain of a ship doomed to sink.  That model of care is not what internists were trained to do.  That model does not require an internist.  It can be provided by an independent nurse practitioner.  That model is what insurance has forced them to become.  As a hospitalist trained in internal medicine, I have the luxury of practicing outside the time constraints of a fee for service system, were volume rules and patients suffer.  I have left the game of glorified triage artist. 

I am trained to manage the vast majority of most chronic medical conditions that do not require procedural or surgical intervention.  I won't call consultants just because I don't want to deal with a problem.  I'll deal the problem  because I am trained to deal with it.   I will call another subspecialist when my skills to manage a condition are lacking.  And because of that, they can rest assured they will only hear from me when I have a question that needs to be answered, not because I don't want to deal with a problem.  

For some docs, that might offend them. They want to be called on their patients. The problem is, I am qualified to manage their patient because the patient is my patient until I have a question that needs to be answered.  If I don't need help evaluating a patient, I won't ask for that help.

I respect their expertise.  I would expect them to respect mine as well.  I often get into these  consulting issues with patients as well.  In fact, some patients demand that subspecialists see them for conditions I am more than qualified to handle.  Stroke patients, COPD and pneumonia patients, heart failure patients often ask why a neurologist or a lung doctor or the cardiologist hasn't been around. After explaining to them what I do as a hospitalist most patients are perfectly happy with the care they receive from me.

The failure of patients to understand what I do is not their fault.  It's a failure of internists and our specialty societies to market our subspecialty to the lay public and to help them understand exactly what it is we do as internists.  Patients should want an internist managing their illness.  They should want a hospitalist leading their ship as the full service crew.  They should demand it. 

Do you want an example of a patient of mine?  Here's what internists are trained to manage, independently, without subspecialty assistance.    A 58 year old male with no available records presents  unresponsive  to the ER after three weeks of nausea, vomiting  and abdominal pain.   He is found to have
  • Glucose 1500
  • Lactic acidosis
  • Gap metabolic acidosis
  • Amylase 1500
  • Potassium level of 1.1
  • Phosphorus level <1
  • Sustained ventricular tachycardia
  • Alcohol withdrawal seizure
  • Upper GI bleed
  • Acute Renal Failure
  • Severe Hypotension
  • Jaundice
  • Dilated common bile duct with prior  chole
  • Severe protein malnutrition
  • Acute hypoxemic respiratory failure
  • Lack of safe IV access.
This is not primary care.  This is  internal medicine.  What is an internist?  An internist is not a primary  care doctor.   An internist is the doctor's doctor.  Just ask for us by name.  Make sure to read  The House of God, a classic that needs no explanation.  

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