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Internal medicine in the 21st century, from skill to approach
The Netherlands Journal of Medicine 1999;55:254–256
Internal medicine in the 21st century, from skill to approach D.W. Erkelens* University Medical Centre, Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
Education and licence to practice the three pillars of the healing practice, i.e. medicine, surgery and obstetrics, was legalised in the second half of the 19th century. The medical doctor as contrasted to the surgical mister and the obstetrical midwife, is best described ` in the manner of Moliere’s caricature. In a long black robe with a tall conical black hat and an enema-syringe in his hands. ` when things went right the According to Moliere doctor claimed to have achieved this, and when things went wrong it was due to the doing of the Almighty. When the term medicine gained a wider significance encompassing all aspects of the science of understanding and fighting disease, the term internal medicine was born. With the aim to delineate it from subspecialisms such as cardiology, neurology and nephrology, the eponym general internal medicine was introduced. In my view this is a misnomer. And I think the next century will prove me right. Internal medicine is not a set of skills, it is an approach to the ill or threatened human individual. In this respect the next century will probably even see a disappearance of the addition ‘‘internal’’ and a return to ‘‘medicine’’. Let me try to explain what I mean. Most diseases originate from a combination of variation in genetic make-up, or nature, and the influence thereupon of the environment, nurture. *Tel.: 1 31-31-2507-399; fax: 1 31-30-2518-328.
The medical doctor has a profound knowledge of both and is able to give an overview of the process when a person falls ill. He does so with human understanding of the social and psychological situation the patients is in, and can consider the importance of diagnostic and therapeutic options against the background of his knowledge and understanding. It is of no importance whether the illness under consideration resides in the heart, the brain or the kidney. Let me give an example: A patient reports to the emergency room with chest pain. It may well happen today that the cardiologist is called, takes a short history, does a quick physical examination, orders an ECG and the measurement of certain enzymes in the blood, and tells the patient that there is nothing wrong with his heart when ECG and laboratory findings are within normal limits. The internist, or medical doctor, in my view should do the same and tell the patient: ‘‘you have chest pain, there is nothing wrong with your heart, and now we will have to find out what else might be causing the chest pain. Meanwhile I will prescribe you something to ease your pain’’. The approach of the internist to a patient is to try to perform the most valuable diagnostic procedures, and to advise the best treatment available, including doing nothing, respecting the prognosis of the individual. You may say at this point that there is no difference in my description of an internist and a general practitioner. You are partly right, but I made a number of remarks that may define the internist.
0300-2977 / 99 / $ – see front matter 1999 Elsevier Science B.V. All rights reserved. PII: S0300-2977( 99 )00105-9
D.W. Erkelens / Internal Medicine
255
First he should have a profound knowledge of both, that is both genetic make-up and the influence of environment, including nutrition, micro-organisms, toxic substances, pharmaceutical agents, and physical damage. Second he should be able to perform the most valuable diagnostic procedures. Therefore he should know what this entails. And third he should advice the best treatment available which also requires detailed information and the ability to objectively weigh advantage versus disadvantage. To achieve this the knowledge necessary is more than for general physicians. In a more practical way, direct access to and hands on experience of most diagnostic procedures and therapeutical interventions is necessary. Or, the internist should be hospital based. So far about approach. It goes without saying that skills are necessary prerequisites. Since the field of medicine is so enormous, it is a must that the internist chooses at some point in time to develop knowledge and skills in one specific field more than in other fields. It is therefore obvious that after a general education one internist can gain more knowledge about the heart, another about the brain and nerves and a third about the kidney. They are unified by their approach to the patients as described above and separated by their specific knowledge and applied performing abilities. What has all this to do with the 21st century? It brings practical consequences for education, medical practice and hospital organisation. We will see in the next century that the principles as described will have a profound, altering, influence in all three.
Whereas up to recently in affected families the patients were screened regularly for the development of medullary thyroid carcinoma by palpation of the neck and operated upon if necessary, nowadays DNA diagnosis is performed in babies and thyroidectomy follows if the test is positive. In the removed thyroids abnormal cells are found that would only much later develop into then fatal carcinoma. I think that the next century will see much more genetic diagnosis at an early stage with direct clinical consequences. Therefore knowledge of genetics is indispensible for internists. The same goes for the other ‘‘horizontal’’ principles of single or multiple organ disease: disturbed immunology, abnormal cell growth, infectious organisms, mal-circulation, abnormal metabolism, over- or underfunction of the hormonal system and (pharmaco-) toxicology. It takes us too far to give examples of each, but let me provide the reader with one more suggestion for internist-education in the future. Circulation is a vital function, providing the delivery of oxygen and nutrients to all tissues. It is of increasing importance to know and understand the pathophysiology of the vascular system. Not only endothelial function and vascular tension but also promotion and inhibition of vascular new-growth or angiogenesis greatly influence pathology. Potentially in the next century anti-angiogenic agents will become an additional tool for the oncologist to prevent tumour growth while pro-angiogenic agents will be helpful for the treatment of atherosclerotic and microvascular disease patients, to stimulate new vessel formation.
Education
Hospital organisation
It is necessary for the internist to receive schooling, continuing education, and regular updating of knowledge in the various general principles of health and disease. I already mentioned a profound knowledge of genetics. This field is influencing every day medical practice much more than in the last century. A foremost example in my eyes is the so called Multiple Endocrine Neoplasia Syndrome. The transition has been made from palpation to fingerprinting.
The practical setting of the internist provides the physical background for the education. He has to work mainly in a clinical environment, in the intensive care unit, as a consultant towards other specialists and in the outpatient clinic. He should be versed to apply his knowledge in all four settings. The next century will certainly see an increase in outpatient activities as more and more diagnostic procedures can be shortened and treatment be provided in the patient’s own home. The same holds true for day-
The Netherlands Journal of Medicine 1999;55:254 – 256
256
D.W. Erkelens / Internal Medicine
care and intensive care. Hospitals should anticipate on these developments and offer space and organisation to make this shift away from the classical hospital-bed setting possible. Was the ward the centre of the hospital universe in the beginning of the twentieth century, being diagnostic unit, corridor, treatment centre, conference area and doctor’s office all in one, in the next century the outpatient clinic will take its place. To facilitate patient handling the outpatient clinic should become much more patient and problem oriented than doctor, organ, or subspecialty oriented. The internist will have to cooperate here with nurse and paramedical personnel teams.
Prevention Since the knowledge of pathophysiologic mechanisms and the natural history of diseases is increasing, the medical doctor is able to foresee what is going to happen and when it is likely to occur. Preventive measures, not only lifestyle advice but also preventive therapy can be necessary. It is the particular realm of the internist to advise about these forms of treatment. It is not necessary that he has the unique position to apply them. Most preventive measures can better be taken on a population wide scale, by the health authorities and for the individual by the general physician.
Medical practice Conclusions We have emphasised the need for profound knowledge of general disease mechanisms by the internist. In order to be able to apply this fundamental knowledge to diseased individuals he needs to choose, as mentioned, the best available diagnostic and therapeutic procedures. This requires knowledge of the methods to ascertain diagnostic values of tests and evidence based therapeutic interventions. It will require in the next century quick access to the latest data and meta-analyses. Distribution by specialty journals is too slow and too diverse. It is proposed that an electronic medi-net is called into existence where the latest treatment protocols are given. The internist, who is au courant with the history and present situation of the patient, will have to apply these readily available protocols to the problem of the individual. He will have to provide the human touch to the electronic prescription.
Internal medicine in the next century will be characterised by an integrated approach to the individual patient. Based on a thorough knowledge of heredity and mechanisms of disease the internist will provide applied advice on diagnosis and treatment to the individual patient. The activities in the outpatient department, the day care centre and the intensive care unit will increase, while the classical ward will decrease in importance. This (internal) medical approach should be a tool of all organ-specialists, not only of the ‘‘general’’ internist, but of cardiologist, neurologist, nephrologist etc., alike. Therefore a return to medicine in its original sense is most desirable.
The Netherlands Journal of Medicine 1999;55:254 – 256
Internal medicine in the 21st century, from skill to approach D.W. Erkelens* University Medical Centre, Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
Education and licence to practice the three pillars of the healing practice, i.e. medicine, surgery and obstetrics, was legalised in the second half of the 19th century. The medical doctor as contrasted to the surgical mister and the obstetrical midwife, is best described ` in the manner of Moliere’s caricature. In a long black robe with a tall conical black hat and an enema-syringe in his hands. ` when things went right the According to Moliere doctor claimed to have achieved this, and when things went wrong it was due to the doing of the Almighty. When the term medicine gained a wider significance encompassing all aspects of the science of understanding and fighting disease, the term internal medicine was born. With the aim to delineate it from subspecialisms such as cardiology, neurology and nephrology, the eponym general internal medicine was introduced. In my view this is a misnomer. And I think the next century will prove me right. Internal medicine is not a set of skills, it is an approach to the ill or threatened human individual. In this respect the next century will probably even see a disappearance of the addition ‘‘internal’’ and a return to ‘‘medicine’’. Let me try to explain what I mean. Most diseases originate from a combination of variation in genetic make-up, or nature, and the influence thereupon of the environment, nurture. *Tel.: 1 31-31-2507-399; fax: 1 31-30-2518-328.
The medical doctor has a profound knowledge of both and is able to give an overview of the process when a person falls ill. He does so with human understanding of the social and psychological situation the patients is in, and can consider the importance of diagnostic and therapeutic options against the background of his knowledge and understanding. It is of no importance whether the illness under consideration resides in the heart, the brain or the kidney. Let me give an example: A patient reports to the emergency room with chest pain. It may well happen today that the cardiologist is called, takes a short history, does a quick physical examination, orders an ECG and the measurement of certain enzymes in the blood, and tells the patient that there is nothing wrong with his heart when ECG and laboratory findings are within normal limits. The internist, or medical doctor, in my view should do the same and tell the patient: ‘‘you have chest pain, there is nothing wrong with your heart, and now we will have to find out what else might be causing the chest pain. Meanwhile I will prescribe you something to ease your pain’’. The approach of the internist to a patient is to try to perform the most valuable diagnostic procedures, and to advise the best treatment available, including doing nothing, respecting the prognosis of the individual. You may say at this point that there is no difference in my description of an internist and a general practitioner. You are partly right, but I made a number of remarks that may define the internist.
0300-2977 / 99 / $ – see front matter 1999 Elsevier Science B.V. All rights reserved. PII: S0300-2977( 99 )00105-9
D.W. Erkelens / Internal Medicine
255
First he should have a profound knowledge of both, that is both genetic make-up and the influence of environment, including nutrition, micro-organisms, toxic substances, pharmaceutical agents, and physical damage. Second he should be able to perform the most valuable diagnostic procedures. Therefore he should know what this entails. And third he should advice the best treatment available which also requires detailed information and the ability to objectively weigh advantage versus disadvantage. To achieve this the knowledge necessary is more than for general physicians. In a more practical way, direct access to and hands on experience of most diagnostic procedures and therapeutical interventions is necessary. Or, the internist should be hospital based. So far about approach. It goes without saying that skills are necessary prerequisites. Since the field of medicine is so enormous, it is a must that the internist chooses at some point in time to develop knowledge and skills in one specific field more than in other fields. It is therefore obvious that after a general education one internist can gain more knowledge about the heart, another about the brain and nerves and a third about the kidney. They are unified by their approach to the patients as described above and separated by their specific knowledge and applied performing abilities. What has all this to do with the 21st century? It brings practical consequences for education, medical practice and hospital organisation. We will see in the next century that the principles as described will have a profound, altering, influence in all three.
Whereas up to recently in affected families the patients were screened regularly for the development of medullary thyroid carcinoma by palpation of the neck and operated upon if necessary, nowadays DNA diagnosis is performed in babies and thyroidectomy follows if the test is positive. In the removed thyroids abnormal cells are found that would only much later develop into then fatal carcinoma. I think that the next century will see much more genetic diagnosis at an early stage with direct clinical consequences. Therefore knowledge of genetics is indispensible for internists. The same goes for the other ‘‘horizontal’’ principles of single or multiple organ disease: disturbed immunology, abnormal cell growth, infectious organisms, mal-circulation, abnormal metabolism, over- or underfunction of the hormonal system and (pharmaco-) toxicology. It takes us too far to give examples of each, but let me provide the reader with one more suggestion for internist-education in the future. Circulation is a vital function, providing the delivery of oxygen and nutrients to all tissues. It is of increasing importance to know and understand the pathophysiology of the vascular system. Not only endothelial function and vascular tension but also promotion and inhibition of vascular new-growth or angiogenesis greatly influence pathology. Potentially in the next century anti-angiogenic agents will become an additional tool for the oncologist to prevent tumour growth while pro-angiogenic agents will be helpful for the treatment of atherosclerotic and microvascular disease patients, to stimulate new vessel formation.
Education
Hospital organisation
It is necessary for the internist to receive schooling, continuing education, and regular updating of knowledge in the various general principles of health and disease. I already mentioned a profound knowledge of genetics. This field is influencing every day medical practice much more than in the last century. A foremost example in my eyes is the so called Multiple Endocrine Neoplasia Syndrome. The transition has been made from palpation to fingerprinting.
The practical setting of the internist provides the physical background for the education. He has to work mainly in a clinical environment, in the intensive care unit, as a consultant towards other specialists and in the outpatient clinic. He should be versed to apply his knowledge in all four settings. The next century will certainly see an increase in outpatient activities as more and more diagnostic procedures can be shortened and treatment be provided in the patient’s own home. The same holds true for day-
The Netherlands Journal of Medicine 1999;55:254 – 256
256
D.W. Erkelens / Internal Medicine
care and intensive care. Hospitals should anticipate on these developments and offer space and organisation to make this shift away from the classical hospital-bed setting possible. Was the ward the centre of the hospital universe in the beginning of the twentieth century, being diagnostic unit, corridor, treatment centre, conference area and doctor’s office all in one, in the next century the outpatient clinic will take its place. To facilitate patient handling the outpatient clinic should become much more patient and problem oriented than doctor, organ, or subspecialty oriented. The internist will have to cooperate here with nurse and paramedical personnel teams.
Prevention Since the knowledge of pathophysiologic mechanisms and the natural history of diseases is increasing, the medical doctor is able to foresee what is going to happen and when it is likely to occur. Preventive measures, not only lifestyle advice but also preventive therapy can be necessary. It is the particular realm of the internist to advise about these forms of treatment. It is not necessary that he has the unique position to apply them. Most preventive measures can better be taken on a population wide scale, by the health authorities and for the individual by the general physician.
Medical practice Conclusions We have emphasised the need for profound knowledge of general disease mechanisms by the internist. In order to be able to apply this fundamental knowledge to diseased individuals he needs to choose, as mentioned, the best available diagnostic and therapeutic procedures. This requires knowledge of the methods to ascertain diagnostic values of tests and evidence based therapeutic interventions. It will require in the next century quick access to the latest data and meta-analyses. Distribution by specialty journals is too slow and too diverse. It is proposed that an electronic medi-net is called into existence where the latest treatment protocols are given. The internist, who is au courant with the history and present situation of the patient, will have to apply these readily available protocols to the problem of the individual. He will have to provide the human touch to the electronic prescription.
Internal medicine in the next century will be characterised by an integrated approach to the individual patient. Based on a thorough knowledge of heredity and mechanisms of disease the internist will provide applied advice on diagnosis and treatment to the individual patient. The activities in the outpatient department, the day care centre and the intensive care unit will increase, while the classical ward will decrease in importance. This (internal) medical approach should be a tool of all organ-specialists, not only of the ‘‘general’’ internist, but of cardiologist, neurologist, nephrologist etc., alike. Therefore a return to medicine in its original sense is most desirable.
The Netherlands Journal of Medicine 1999;55:254 – 256