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Internal medicine in Greece
European Journal of Internal Medicine 10 Ž1999. 225–228 www.elsevier.comrlocaterejim
Internal Medicine in Europe
Internal medicine in Greece S.A. Raptis ) , G. Chalevelakis Hellenic Society of Internal Medicine, P.O. Box 17151, Athens GR 10024, Greece Received 10 June 1999; received in revised form 17 June 1999; accepted 9 September 1999
Keywords: Internal medicine; Greece; Internist
1. History It was in Germany around 1880 that the term ‘internal medicine’ Ž‘Innere Medizin’. was first introduced to emphasize the importance of pathophysiological alterations in internal organs. The basic skills for internal medicine, which are taking the patient’s history and performing the physical examination using all of the senses, centering on observation and logic, have remained identical since the time of Hippocrates. Keywords, such as ‘Hippocratic face’, ‘carphology’, ‘Hippocratic fingers’, and ‘tetanus’, are still used on occasion. The current goals of internal medicine Ždiagnosis, prognosis, therapy, and prevention. also remain the same as those in Hippocrates’ time. In the ‘Orders of the Hippocratic Collection’, it is clearly stated that ‘‘where exactly there is love for the human being, there is love for the art of medicine waccording to Hippocratesx too’’. To respect the individual’s dignity and personality during this age of technology is an absolute ‘must’ if man is to remain the core of medicine.
2. Training in internal medicine
those in former Eastern European countries. return to Greece, where their degree in medicine is recognized after taking a special examination before the Ministry of Health and Welfare. These graduates are added to the ‘pool’ of those waiting on a priority list for residency programs. The training in internal medicine lasts 5 years. 2.2. Residency centers Candidates begin their residency without examinations. Residency is based on a priority list, and the amount of time on the waiting list varies, depending on the center, specialty and the time. The larger hospitals Žuniversity hospitals all around the country and the national health system’s hospitals in Athens and Thessaloniki. provide a full 5-year training in internal medicine. The smaller hospitals usually provide 1–2 years of training, depending on the size, infrastructure, and staff available. There are a total of 128 hospitals providing training in internal medicine in Greece. 2.3. Training
2.1. Undergraduate training After taking competitive examinations ŽPanhellenic exams., selected students enter medical school, where they study 6 years at one of the seven medical schools around the country ŽAthens, Thessaloniki, Patra, Alexandroupolis, Ioannina, Heraklion of Crete, and Larissa.. A significant number of graduates of foreign medical schools Žespecially
) Corresponding author. Second Department of Internal Medicine, Athens University, Athens 100 24, Greece
Training in internal medicine includes the following. Ž1. Clinical training in the wards. Each resident is responsible for four to six beds. Ž2. Participation in scheduled educational programs and seminars organized in the hospital, for which the director of the department or hospital is responsible, and within the framework of the local hospital scientific unions. Ž3. Participation and experience in general continuity medicine clinics, walk-in clinics, and subspecialty consultation clinics. Ž4. Participation in the ambulatory care center program. Ž5. Participation in the emergency rooms program.
0953-6205r99r$ - see front matter q 1999 Published by Elsevier Science B.V. All rights reserved. PII: S 0 9 5 3 - 6 2 0 5 Ž 9 9 . 0 0 0 5 7 - 6
226
S.A. Raptis, G. ChaleÕelakisr European Journal of Internal Medicine 10 (1999) 225–228
Ž6. Training and credentials to perform all internal medicine procedures: fundoscopy, rhinogastric tube placement, central lines, arterial lines insertion, tracheal intubation, bladder catheterization, lumbar puncture, bone marrow aspiration and biopsy, paracentesis, ACLS, CPR Žduring the rotation at the intensive care unit., and occasionally more invasive procedures such as liver biopsy. Ž7. Participation in basic research or clinical research Žespecially in the university departments. or in collaboration with them in the context of sponsorship programs from the European Community, which may result in the completion of a doctoral thesis, and even in a Greek or international medical journal publication. 2.4. Rotation During the 4th year of the residency, a 3-month training in the intensive care unit, and additional 3 months in a cardiology department, is mandatory. 2.5. Educators The educators, mainly internists, include the department directors, deputy directors, or visiting professors or professors in the university clinics. 2.6. Training eÕaluation No national evaluation system is available in Greece, nor is there a logbook Ž‘training record’.. 2.7. Problems during training Unfortunately, due to significant changes in the quality of patient cases treated in the departments of internal medicine in recent years, residents are not exposed to the broad spectrum of diseases they should be trained in. The only solution to this limited exposure to internal diseases lies in the idea of rotation. 2.8. Duration of training and certification in internal medicine The training in internal medicine lasts for 5 years. Upon completion of the training program, a certification is granted, signed by the respective director and validated by the hospital’s scientific board Ždepartment manager, president of the scientific committee..
3. Subspecialties of internal medicine Current hyperspecialization in medicine should be considered a natural development from the subspecialty trend, already present in Hippocrates’ time Že.g. surgery, orthopedics, and obstetrics–gynecology.. Therefore, the supersubspecialization occurring in the field of internal medicine, as in the other main disciplines of medicine, is more than expected. 3.1. Internal medicine as a specialty in Greece Internal medicine has been acknowledged as a specialty in Greece since 1936. 3.2. Reasons for the rapid increase in subspecialties worldwide and in Greece Ž1. The explosive increase in knowledge in medicine and biology since the second World War. Ž2. The tremendous development in medical biotechnology. Ž3. The better fees for doctors with a subspecialty. Ž4. The significant emphasis on specialized knowledge, without equal attention to the value of applied clinical medicine by the medical press, mass communication, and pharmaceutical companies. 3.3. Impact of the oÕerexpansion of subspecialties on the main trunk of internal medicine 1. Fragmentation of the discipline of internal medicine. 2. Constant decrease in the number of purely clinical physicians. 3. Patient shift towards subspecialists. 4. Overuse of modern technology. 5. Increase in iatrogenic morbidity. 6. Inability to resolve complex medical problems, resulting in physical and physiological distress on the part of the patient. 7. Limitation on the humanitarian and holistic profile of medicine. 8. Significant increase in health care costs for the patient, the hospital, social security and, eventually, the country.
2.9. Acquisition of specialty title
3.4. Subspecialties recognized in Greece (listed in alphabetical order)
The specialty title is acquired after both oral and written examinations Žheld four times annually. before a three-part committee of the Ministry of Health and Welfare, headed by a medical school professor ŽOrdinarius..
For all of the following subspecialties, a 6-month to 2-year training in internal medicine is required: allergiology, cardiology, dermatology, endocrinology, gastroenterology, general medicine Žfamily practice., geriatrics,
S.A. Raptis, G. ChaleÕelakisr European Journal of Internal Medicine 10 (1999) 225–228
hematology, internal medicine, nephrology, nuclear medicine, occupational medicine, oncology, pediatrics, physical medicine, and rheumatology.
227
6. Problems encountered while practicing internal medicine 6.1. Public hospitals
3.5. Sub-subspecialization A tendency to subspecialize in more focused gnostic objectives, such as infectious diseases, diabetes mellitus, ultrasonography, etc. has grown in recent years.
4. Number of specialists in internal medicine There are a total of 40 000 physicians in Greece, 40% Ž16 000. of whom serve in public positions. Internists make up 11% of the total number of medical doctors; in absolute numbers that translates to 4500 certified internists. It should be highlighted, though, that there is no national policy program for manpower planning for the physicians or for the number of doctors needed per specialty.
5. Entrance of the specialists into the active medical practice
The hospital physician, in order to meet his patients’ needs, spends valuable time on nonmedical duties, due to the lack of supportive and nursing staff, and to the lack of a computerized archiving system. The constant, demanding duties in the emergency room exert a negative effect on the physical and psychological status of the doctor, limiting the possibility, or his willingness, to take part in educational programs. On top of this, the nature of the diseases that physicians are confronted with in the public hospitals has changed dramatically during the last decade. Patients are mainly elderly Ž) 80 years old. with chronic diseases, or they have with serious social problems Žalcoholism, drug dependency, homelessness.. These patients hang around in the departments and are not the appropriate ‘model’ for educational or scientific purposes. Yet, they are in need of primary or supportive care, something that is not sufficiently provided to this group in our country. Interesting diagnostic and therapeutic cases in the field of internal medicine are turned over to subspecialists, or to the private sector. In this way, neither those working in the private sector nor subspecialists have to deal with the abovementioned chronic diseases.
5.1. PriÕate sector 6.2. PriÕate sector The majority of specialists work out of private medical offices, though occasionally there is simultaneous collaboration with a private hospital. Nevertheless, the income derived from the private office is not particularly satisfactory, given the increased manpower available and the intense competition that results. 5.2. Public sector The public sector consists of public hospitals and health centers, as well as university hospitals or departments housed in the national health system’s hospitals. The positions available Žespecially at the university, due to the permanent status of their members. are limited, the fees are moderate, and for the physician with a position in the national health system, there is no possibility of having a private office as well.
There is a continuous decrease in the number of patients referred to a general internist without a subspecialization. At the same time, the exaggerated number of physicians in the private sector, compared to those seeking a place in it, has resulted in unacceptably low fees. An additional disturbing phenomenon is the decline in the prestige of the internist, even on a governmental policy level, e.g. nonverification of the internist’s signature for authorization of legal actions, on drug prescriptions, orders for imaging examinations, or certifications by social security or other security groups of controller-physicians. Frequently, the title of ‘specialised internist’ is confused with that of ‘general doctor’ who, under some circumstances Žhealth centers., supervises the latter. The nonexistence of a wellorganized continuous medical education program contributes to the social decline in prestige and the scientific demotivation of the internist in Greece.
5.3. Social security groups Physicians working in the social security sector, either on a permanent basis or under a contract for a limited or unlimited amount of time, offer their services as family practitioners or primary health caregivers in a regular outpatient practice. The possibility of also having a private office is determined on an individual basis.
7. Greek association of internal medicine 7.1. Foundation and goal The Hellenic Society of Internal Medicine was founded in 1987 and consists of approximately 500 registered
228
S.A. Raptis, G. ChaleÕelakisr European Journal of Internal Medicine 10 (1999) 225–228
members. It deals with internists’ occupational issues as well as with scientific issues, and will continue to do so until the newly founded Occupational Union of Internists becomes completely functional and takes over the former issues. 7.2. Educational and other actiÕities The need to establish a national foundation became apparent in recent years, mainly due to the underestimated reputation of the internist in Greece. The Society’s intense efforts have resulted in significant achievements, especially in the field of postgraduate education. Moreover, scientific conferences, including presentations of selected contemporary scientific topics by distinguished guest speakers and presentations of interesting cases, take place on a monthly basis. In cooperation with the Panhellenic Medical Union and local medical associations, symposia are organized in different cities around Greece on a regular basis Žtwo to three times per year.. In addition, five Panhellenic and one European Žthe 13th. Congress of Internal Medicine have taken place with great success. At the same time, the Society, by placing pressure on and negotiating with government representatives, has greatly contributed to the resolution of serious financial and administrative problems related to the practice of internal medicine. Recently, the Hellenic Society of Internal Medicine submitted a complete curriculum for the discipline of internal medicine to the Ministry of Health and Welfare for approval. 7.3. Immediate priorities and perspectiÕes The Hellenic Society of Internal Medicine is determined to exert pressure on the Ministry of Health and Welfare in order to eventually establish the submitted proposal for a 5-year training program for all major subspecialties directly related to internal medicine Žendocrinology, rheumatology, etc... According to the proposed schedule, 2 additional years should follow in order to complete the desired subspecialization. Furthermore, it is suggested that the 5-year training in internal medicine be divided into three periods. 7.3.1. 1st and 2nd years Emphasis on clinical assessment of the patient and training in diagnosis and treatment. The primary educational goal of the 1st year in the residency training program should be to enable the resident to develop a high level of competence in caring for sick patients on a continuing, day-to-day basis. An appropriate amount of supervision by senior residents in internal medicine should be provided. Specifically the 1st-year resident should perform the initial patient work-up, write
the orders, discuss the diagnostic and therapeutic plans with the senior resident or attending physician, and personally implement much of his or her plan. This experience must be accompanied by a thoughtful critique by the faculty on the resident’s diagnostic and therapeutic decisions. The resident should gain experience in the management of ambulatory patients through continuity clinic assignments 1r2 day each week and attendance at the other general medicine and subspecialty clinics. These experiences should be integrated into the concurrent in-patient assignments. 7.3.2. 3rd and 4th years Emphasis on differential diagnosis, CPCs, increased responsibility for outpatients, and two to three rotations in the main subspecialties, such as cardiology, critical care ŽMICU, CCU. and pneumology. There should be four principal educational goals of the 2nd and 3rd years of residency training: 1. To foster the resident’s ability to provide effective, efficient, and comprehensive care to patients with internal medicine problems; 2. To give the resident the opportunity to study and analyze in-depth complex problems in internal medicine; 3. To help the resident acquire a substantial core of information in internal medicine; 4. To train the resident to serve as a good consultant in internal medicine to other physicians. The target of the training program up until completion of the 4th year is not designed to train a specific type of internist, such as a general internist, subspecialist, or academician. Rather, the program is intended to provide a sound and practical basis for any type of career the resident follows. 7.3.3. 5th year Selection of one or more areas of interest and to prevent any further fragmentation of internal medicine. Training progress examinations are proposed for the end of the 2nd and the 4th years. During all of the years of training, standard ‘grand’ rounds and state-of-the art lectures should be provided. Furthermore, there should be case presentations with discussions. The presentations should cover topics related to internal medicine, as well as those from the medical subspecialties. Discussions of medical ethics should be part of the program. Senior residents and fellows should present topics of clinical interest and journal reviews Žreviews of important medical articles.. Providing the broadest and most complete clinical experience possible, together with the standard orientation in a concise and fair training program in internal medicine, seems the rational way to proceed for a better holistic approach to the patient and for a better professional quality of life for the internist.
Internal Medicine in Europe
Internal medicine in Greece S.A. Raptis ) , G. Chalevelakis Hellenic Society of Internal Medicine, P.O. Box 17151, Athens GR 10024, Greece Received 10 June 1999; received in revised form 17 June 1999; accepted 9 September 1999
Keywords: Internal medicine; Greece; Internist
1. History It was in Germany around 1880 that the term ‘internal medicine’ Ž‘Innere Medizin’. was first introduced to emphasize the importance of pathophysiological alterations in internal organs. The basic skills for internal medicine, which are taking the patient’s history and performing the physical examination using all of the senses, centering on observation and logic, have remained identical since the time of Hippocrates. Keywords, such as ‘Hippocratic face’, ‘carphology’, ‘Hippocratic fingers’, and ‘tetanus’, are still used on occasion. The current goals of internal medicine Ždiagnosis, prognosis, therapy, and prevention. also remain the same as those in Hippocrates’ time. In the ‘Orders of the Hippocratic Collection’, it is clearly stated that ‘‘where exactly there is love for the human being, there is love for the art of medicine waccording to Hippocratesx too’’. To respect the individual’s dignity and personality during this age of technology is an absolute ‘must’ if man is to remain the core of medicine.
2. Training in internal medicine
those in former Eastern European countries. return to Greece, where their degree in medicine is recognized after taking a special examination before the Ministry of Health and Welfare. These graduates are added to the ‘pool’ of those waiting on a priority list for residency programs. The training in internal medicine lasts 5 years. 2.2. Residency centers Candidates begin their residency without examinations. Residency is based on a priority list, and the amount of time on the waiting list varies, depending on the center, specialty and the time. The larger hospitals Žuniversity hospitals all around the country and the national health system’s hospitals in Athens and Thessaloniki. provide a full 5-year training in internal medicine. The smaller hospitals usually provide 1–2 years of training, depending on the size, infrastructure, and staff available. There are a total of 128 hospitals providing training in internal medicine in Greece. 2.3. Training
2.1. Undergraduate training After taking competitive examinations ŽPanhellenic exams., selected students enter medical school, where they study 6 years at one of the seven medical schools around the country ŽAthens, Thessaloniki, Patra, Alexandroupolis, Ioannina, Heraklion of Crete, and Larissa.. A significant number of graduates of foreign medical schools Žespecially
) Corresponding author. Second Department of Internal Medicine, Athens University, Athens 100 24, Greece
Training in internal medicine includes the following. Ž1. Clinical training in the wards. Each resident is responsible for four to six beds. Ž2. Participation in scheduled educational programs and seminars organized in the hospital, for which the director of the department or hospital is responsible, and within the framework of the local hospital scientific unions. Ž3. Participation and experience in general continuity medicine clinics, walk-in clinics, and subspecialty consultation clinics. Ž4. Participation in the ambulatory care center program. Ž5. Participation in the emergency rooms program.
0953-6205r99r$ - see front matter q 1999 Published by Elsevier Science B.V. All rights reserved. PII: S 0 9 5 3 - 6 2 0 5 Ž 9 9 . 0 0 0 5 7 - 6
226
S.A. Raptis, G. ChaleÕelakisr European Journal of Internal Medicine 10 (1999) 225–228
Ž6. Training and credentials to perform all internal medicine procedures: fundoscopy, rhinogastric tube placement, central lines, arterial lines insertion, tracheal intubation, bladder catheterization, lumbar puncture, bone marrow aspiration and biopsy, paracentesis, ACLS, CPR Žduring the rotation at the intensive care unit., and occasionally more invasive procedures such as liver biopsy. Ž7. Participation in basic research or clinical research Žespecially in the university departments. or in collaboration with them in the context of sponsorship programs from the European Community, which may result in the completion of a doctoral thesis, and even in a Greek or international medical journal publication. 2.4. Rotation During the 4th year of the residency, a 3-month training in the intensive care unit, and additional 3 months in a cardiology department, is mandatory. 2.5. Educators The educators, mainly internists, include the department directors, deputy directors, or visiting professors or professors in the university clinics. 2.6. Training eÕaluation No national evaluation system is available in Greece, nor is there a logbook Ž‘training record’.. 2.7. Problems during training Unfortunately, due to significant changes in the quality of patient cases treated in the departments of internal medicine in recent years, residents are not exposed to the broad spectrum of diseases they should be trained in. The only solution to this limited exposure to internal diseases lies in the idea of rotation. 2.8. Duration of training and certification in internal medicine The training in internal medicine lasts for 5 years. Upon completion of the training program, a certification is granted, signed by the respective director and validated by the hospital’s scientific board Ždepartment manager, president of the scientific committee..
3. Subspecialties of internal medicine Current hyperspecialization in medicine should be considered a natural development from the subspecialty trend, already present in Hippocrates’ time Že.g. surgery, orthopedics, and obstetrics–gynecology.. Therefore, the supersubspecialization occurring in the field of internal medicine, as in the other main disciplines of medicine, is more than expected. 3.1. Internal medicine as a specialty in Greece Internal medicine has been acknowledged as a specialty in Greece since 1936. 3.2. Reasons for the rapid increase in subspecialties worldwide and in Greece Ž1. The explosive increase in knowledge in medicine and biology since the second World War. Ž2. The tremendous development in medical biotechnology. Ž3. The better fees for doctors with a subspecialty. Ž4. The significant emphasis on specialized knowledge, without equal attention to the value of applied clinical medicine by the medical press, mass communication, and pharmaceutical companies. 3.3. Impact of the oÕerexpansion of subspecialties on the main trunk of internal medicine 1. Fragmentation of the discipline of internal medicine. 2. Constant decrease in the number of purely clinical physicians. 3. Patient shift towards subspecialists. 4. Overuse of modern technology. 5. Increase in iatrogenic morbidity. 6. Inability to resolve complex medical problems, resulting in physical and physiological distress on the part of the patient. 7. Limitation on the humanitarian and holistic profile of medicine. 8. Significant increase in health care costs for the patient, the hospital, social security and, eventually, the country.
2.9. Acquisition of specialty title
3.4. Subspecialties recognized in Greece (listed in alphabetical order)
The specialty title is acquired after both oral and written examinations Žheld four times annually. before a three-part committee of the Ministry of Health and Welfare, headed by a medical school professor ŽOrdinarius..
For all of the following subspecialties, a 6-month to 2-year training in internal medicine is required: allergiology, cardiology, dermatology, endocrinology, gastroenterology, general medicine Žfamily practice., geriatrics,
S.A. Raptis, G. ChaleÕelakisr European Journal of Internal Medicine 10 (1999) 225–228
hematology, internal medicine, nephrology, nuclear medicine, occupational medicine, oncology, pediatrics, physical medicine, and rheumatology.
227
6. Problems encountered while practicing internal medicine 6.1. Public hospitals
3.5. Sub-subspecialization A tendency to subspecialize in more focused gnostic objectives, such as infectious diseases, diabetes mellitus, ultrasonography, etc. has grown in recent years.
4. Number of specialists in internal medicine There are a total of 40 000 physicians in Greece, 40% Ž16 000. of whom serve in public positions. Internists make up 11% of the total number of medical doctors; in absolute numbers that translates to 4500 certified internists. It should be highlighted, though, that there is no national policy program for manpower planning for the physicians or for the number of doctors needed per specialty.
5. Entrance of the specialists into the active medical practice
The hospital physician, in order to meet his patients’ needs, spends valuable time on nonmedical duties, due to the lack of supportive and nursing staff, and to the lack of a computerized archiving system. The constant, demanding duties in the emergency room exert a negative effect on the physical and psychological status of the doctor, limiting the possibility, or his willingness, to take part in educational programs. On top of this, the nature of the diseases that physicians are confronted with in the public hospitals has changed dramatically during the last decade. Patients are mainly elderly Ž) 80 years old. with chronic diseases, or they have with serious social problems Žalcoholism, drug dependency, homelessness.. These patients hang around in the departments and are not the appropriate ‘model’ for educational or scientific purposes. Yet, they are in need of primary or supportive care, something that is not sufficiently provided to this group in our country. Interesting diagnostic and therapeutic cases in the field of internal medicine are turned over to subspecialists, or to the private sector. In this way, neither those working in the private sector nor subspecialists have to deal with the abovementioned chronic diseases.
5.1. PriÕate sector 6.2. PriÕate sector The majority of specialists work out of private medical offices, though occasionally there is simultaneous collaboration with a private hospital. Nevertheless, the income derived from the private office is not particularly satisfactory, given the increased manpower available and the intense competition that results. 5.2. Public sector The public sector consists of public hospitals and health centers, as well as university hospitals or departments housed in the national health system’s hospitals. The positions available Žespecially at the university, due to the permanent status of their members. are limited, the fees are moderate, and for the physician with a position in the national health system, there is no possibility of having a private office as well.
There is a continuous decrease in the number of patients referred to a general internist without a subspecialization. At the same time, the exaggerated number of physicians in the private sector, compared to those seeking a place in it, has resulted in unacceptably low fees. An additional disturbing phenomenon is the decline in the prestige of the internist, even on a governmental policy level, e.g. nonverification of the internist’s signature for authorization of legal actions, on drug prescriptions, orders for imaging examinations, or certifications by social security or other security groups of controller-physicians. Frequently, the title of ‘specialised internist’ is confused with that of ‘general doctor’ who, under some circumstances Žhealth centers., supervises the latter. The nonexistence of a wellorganized continuous medical education program contributes to the social decline in prestige and the scientific demotivation of the internist in Greece.
5.3. Social security groups Physicians working in the social security sector, either on a permanent basis or under a contract for a limited or unlimited amount of time, offer their services as family practitioners or primary health caregivers in a regular outpatient practice. The possibility of also having a private office is determined on an individual basis.
7. Greek association of internal medicine 7.1. Foundation and goal The Hellenic Society of Internal Medicine was founded in 1987 and consists of approximately 500 registered
228
S.A. Raptis, G. ChaleÕelakisr European Journal of Internal Medicine 10 (1999) 225–228
members. It deals with internists’ occupational issues as well as with scientific issues, and will continue to do so until the newly founded Occupational Union of Internists becomes completely functional and takes over the former issues. 7.2. Educational and other actiÕities The need to establish a national foundation became apparent in recent years, mainly due to the underestimated reputation of the internist in Greece. The Society’s intense efforts have resulted in significant achievements, especially in the field of postgraduate education. Moreover, scientific conferences, including presentations of selected contemporary scientific topics by distinguished guest speakers and presentations of interesting cases, take place on a monthly basis. In cooperation with the Panhellenic Medical Union and local medical associations, symposia are organized in different cities around Greece on a regular basis Žtwo to three times per year.. In addition, five Panhellenic and one European Žthe 13th. Congress of Internal Medicine have taken place with great success. At the same time, the Society, by placing pressure on and negotiating with government representatives, has greatly contributed to the resolution of serious financial and administrative problems related to the practice of internal medicine. Recently, the Hellenic Society of Internal Medicine submitted a complete curriculum for the discipline of internal medicine to the Ministry of Health and Welfare for approval. 7.3. Immediate priorities and perspectiÕes The Hellenic Society of Internal Medicine is determined to exert pressure on the Ministry of Health and Welfare in order to eventually establish the submitted proposal for a 5-year training program for all major subspecialties directly related to internal medicine Žendocrinology, rheumatology, etc... According to the proposed schedule, 2 additional years should follow in order to complete the desired subspecialization. Furthermore, it is suggested that the 5-year training in internal medicine be divided into three periods. 7.3.1. 1st and 2nd years Emphasis on clinical assessment of the patient and training in diagnosis and treatment. The primary educational goal of the 1st year in the residency training program should be to enable the resident to develop a high level of competence in caring for sick patients on a continuing, day-to-day basis. An appropriate amount of supervision by senior residents in internal medicine should be provided. Specifically the 1st-year resident should perform the initial patient work-up, write
the orders, discuss the diagnostic and therapeutic plans with the senior resident or attending physician, and personally implement much of his or her plan. This experience must be accompanied by a thoughtful critique by the faculty on the resident’s diagnostic and therapeutic decisions. The resident should gain experience in the management of ambulatory patients through continuity clinic assignments 1r2 day each week and attendance at the other general medicine and subspecialty clinics. These experiences should be integrated into the concurrent in-patient assignments. 7.3.2. 3rd and 4th years Emphasis on differential diagnosis, CPCs, increased responsibility for outpatients, and two to three rotations in the main subspecialties, such as cardiology, critical care ŽMICU, CCU. and pneumology. There should be four principal educational goals of the 2nd and 3rd years of residency training: 1. To foster the resident’s ability to provide effective, efficient, and comprehensive care to patients with internal medicine problems; 2. To give the resident the opportunity to study and analyze in-depth complex problems in internal medicine; 3. To help the resident acquire a substantial core of information in internal medicine; 4. To train the resident to serve as a good consultant in internal medicine to other physicians. The target of the training program up until completion of the 4th year is not designed to train a specific type of internist, such as a general internist, subspecialist, or academician. Rather, the program is intended to provide a sound and practical basis for any type of career the resident follows. 7.3.3. 5th year Selection of one or more areas of interest and to prevent any further fragmentation of internal medicine. Training progress examinations are proposed for the end of the 2nd and the 4th years. During all of the years of training, standard ‘grand’ rounds and state-of-the art lectures should be provided. Furthermore, there should be case presentations with discussions. The presentations should cover topics related to internal medicine, as well as those from the medical subspecialties. Discussions of medical ethics should be part of the program. Senior residents and fellows should present topics of clinical interest and journal reviews Žreviews of important medical articles.. Providing the broadest and most complete clinical experience possible, together with the standard orientation in a concise and fair training program in internal medicine, seems the rational way to proceed for a better holistic approach to the patient and for a better professional quality of life for the internist.