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.