Has the time come for a major overhaul of internal medicine training to better prepare new physicians for the reality of medical practice they will face in the 21st century? Has hospital medicine’s rapid growth been one indication that the roles internists are being asked to perform are in many ways different from just a decade earlier? Are these concerns just as applicable for young family practitioners and pediatricians?
On Dec. 2, 2005, the Alliance for Academic Internal Medicine (AAIM) and the American Board of Internal Medicine (ABIM) brought together more than 40 of the key opinion leaders in internal medicine to look into these very issues. This watershed meeting included the top leaders at ABIM, the American College of Physicians (ACP), the Association of Program Directors in Internal Medicine (APDIM), the Association of Professors of Medicine (APM), all of the medical subspecialty societies, the American Medical Association (AMA), the AMA/Specialty Society RVS Update Committee (RUC), and the American Association of Medical Colleges (AAMC). And, yes, SHM, was well represented.
In addition to agreeing that an overhaul of internal medicine residency training is long overdue, part of this meeting was also devoted to potential changes in the maintenance of certification process to allow for formal recognition of expertise in hospital medicine and ambulatory internal medicine. More about that later.
APDIM and APM, representing the collective organizations in AAIM, presented a plan for revision in training that would identify a core of internal medicine that could form the basis for the front end of training (e.g., possibly the first two years) and allow for a concentration in the later stages of internal medicine residencies. This might take the form of a third year with an emphasis in hospital medicine, ambulatory medicine, traditional internal medicine, or one of the medical subspecialties.
Amazingly, this approach was almost universally accepted by the attendees at the Dec. 2 meeting. With this broad support, AAIM plans to push forward in the coming months, disseminating details of their plan with an opportunity for a broader comment on just what would constitute the “core” of internal medicine. APM and APDIM then plan to take this input and come back by midyear with a more fleshed out proposal.
Of interest is that SHM is publishing the Core Competencies in Hospital Medicine as a supplement to the first issue of the Journal of Hospital Medicine. The work hospitalist thought leaders have put into defining these core competencies over the last few years should be helpful in providing the hospital medicine slant on the core of internal medicine as well as forming the basis for the curriculum with concentration in hospital medicine in the third year of training.
While the goal is to allow training to reflect the career choices of today’s internists and to better prepare them for their professional lives, the devil is truly in the details. Besides serving as a platform for education, internal medicine residency has evolved into a major service load supporting many health systems. Any revision to internal medicine residency needs to accommodate for the service load. In addition, any changes need to be blended into subspecialty fellowship training.
Weaved into this entire discussion was the evolving reshaping of internal medicine. At one time the well-trained general internist was the consummate well-rounded physician serving as a consultant on many diseases to surgeons and other physicians. The last quarter of the 20th century saw the blossoming of many subspecialties in internal medicine and in the last decade a further sub-subspecialization with endoscopists, electrophysiologists, and the like. As the complexity and demands increased in recent years in both the hospital and the outpatient arena, some internists chose to limit their practice to the hospital or the office, and hospital medicine grew and its competencies became more defined.
As internists further refined their skills and narrowed their professional focus, their expectations of their certification and especially their maintenance of certification (MOC) by the ABIM became an issue. Is the MOC process relevant to what they feel they do and should know?
In addition, many subspecialty societies have concerns about how maintaining a basis in internal medicine fits in with MOC in their subspecialties. At this meeting it became clear that many subspecialists feel there is a core of internal medicine they should continue to know and be evaluated on without being expected to know everything a practicing hospitalist or ambulatory internist knows. For example, a cardiologist may be expected to know when their diabetic patients are getting into trouble and need consultation but may not need to know the intricacies of managing extremes in glycemic control.
Many at this meeting felt that the time is now here for using the MOC process to offer those initially credentialed in general internal medicine to have their MOC evaluation tailored to their real-life practice as a hospitalist or an internist with an ambulatory practice and to allow for them to be identified as having expertise in hospital or ambulatory medicine. This was a recognition that these aspects of what have traditionally been lumped together as general internal medicine have key defined skills and knowledge and needs to be recognized as more than just an internist who is not a subspecialist.
Once again there is still much work to be done. SHM, ACP, SGIM, and others will need to work with ABIM and RUC and others to define the skills and the competencies that would form the basis for the training and evaluation of new and improved internists in the 21st century.
The good news from the Dec. 2, 2005, meeting in Dallas is that the national leadership in internal medicine recognizes the need to change internal medicine residency training and to have an MOC process that is relevant to all internists—general internists, subspecialists, and hospitalists. There was also a sense that this process needs to move forward with reasoned speed. We don’t need to write another white paper and declare victory. Today’s and tomorrow’s internists and our patients need us to provide the leadership to produce the best trained and motivated internists and subspecialists to meet the increasing needs of a sophisticated and aging population.
As always SHM will be there, playing an active role. Whatever we come up with for internal medicine I hope can be applicable to family practice and pediatrics as well. Because this is the professional world you will live in, we will continue to invite your input and ideas. TH
Dr. Wellikson has been CEO of SHM since 2000.