The impending crisis in internal medicine training programs

Abstract

Internal medicine, the specialty that has traditionally attracted the intellectual elite of the medical profession, seems to be headed for hard times. Although a recent survey forecasts an ever increasing number of internists per population in the United States during the coming decades [ 11, even to the point of surfeit, emerging warning signals can be detected. The failure of several outstanding medical internship programs to achieve their quota of interns in the national matching program this year has shaken many leaders of internal medicine out of their complacency [2], and may represent an early harbinger of an impending crisis. Israel, which usually lags behind the United States by several years, is already in the midst of a crisis of major magnitude in internal medicine. Although important differences exist between Israeli and American internal medicine, the Israeli situation may provide important lessons for American internal medicine, and it behooves the leadership of American medicine to examine its internal medicine scene in light of what has already transpired in Israel. Israel, for the past five to 10 years, has experienced an increasing shortage of residents in internal medicine, to the point where dozens of positions in university hospitals are unfilled, and the quality of the applicants has fallen. By attempting to analyze the pathophysiology of the problem, in the best tradition of internal medicine, perhaps solutions may be more readily apparent. Although some of the current observations have been discussed by perceptive observers [2-51, the pervasive magnitude of the problem has not been adequately reflected in the tone of most of the published articles, and a broad comprehensive analysis of the multiplicity of factors is timely. It is essential not to be diverted into focusing on only one or two of the etiologic factors in isolation, neglecting other perhaps more important ones. The classic internal medicine training paradigm represented the thinking man’s ideal, one in which meticulous history taking, detailed physical examination, and reasoned logical analysis were combined in a thoughtful, methodic, and deliberate process. This combination culminated in a diagnostic strategy and ultimately a treatment plan. Ample time was usually available to think, read, and discuss, and to relate to the individual patient and family. The correct diagnosis and treatment and ongoing care were the source of satisfaction derived by the internist who, with the training described by Barondess [6], aspired to be the kind of clinician epitomized by Tumulty [7]. In this classic model, the general internist was a virtuoso of sorts. In some ways, he might be considered the Renaissance man of medicine, familiar with the gamut of the subspecialities, as likely to diagnose an atrial myxoma as subacute thyroiditis, Whipple’s disease, or Felty’s syndrome, and the classic ultimate virtuouso performance was in ferreting out the difficult fever of unknown origin, the ultimate challenge. The ambience was contemplative and erudite. Time was available also by intellectual endeavors beyond immediate patient care. Library work and contributions to the medical literature were commonplace. What has happened to the field of internal medicine as