Internal medicine is one of the core subjects of medicine. It covers the internal diseases of a human being. In the past, neurology and laboratory medicine were also part of this specialty. In previous eras, medical professors would also teach pharmacology as part of internal medicine. The therapeutic approach in internal medicine used to be conservative drug therapy. In modern times, interventional procedures, such as stent implantation in constricted coronary vessels or endoscopic polyp or tumor ablation, are gaining importance. This importance also applies to clinical practice and education. We can diagnose and treat growing numbers of diseases due to the wealth of knowledge acquired through medical research and scientific advancement. The use of more precise diagnostic methods, such as CT and MRI, allows us to increase the speed and accuracy with which we can view the body. Newer-generation sonographic units produce excel- lent high-definition images (Fig. 3.9).

 

Fig. 3.9 Plane of section of a transverse scan.

 

Used by an experienced physician, they can deliver valuable noninvasive insights into disease processes. Therapies for many diseases are subject to constant change. For example, the latest generation of chemotherapeutics in oncology and antiarrhythmics in cardiology have become extremely comprehensive, resulting in the growing compartmentalization of internal medicine. Patients benefit from these developments and physicians should respect that. The time required for postgraduate training reflects the enormous range of areas— and an issue that is the subject of ongoing debate. Postgraduate training takes three years in the United States and five years plus subsequent sub-specialization in European countries. It is safe to say that today no physician is likely to be able to cover the entire spectrum of internal medicine but instead must specialize in certain areas.

In Western countries, internal medicine has split into different areas without the official acceptance of the medical community as a whole. It is nearly impossible for any hospital today to provide care in all specialty areas of internal medicine. Generally, there is an internal medicine department that covers gastroenterology, cardiology, and pulmonology. These areas constitute the traditional polyclinic and can provide care for the majority of patients. The word polyclinic is derived from the Greek word polis, which means “city.” It refers to the traditional city hospital. Other medical historians claim that the word polyclinic is derived from the Greek word polys, which means “many” or “much.” This would apply to a hospital or department that treats many different cases and their origins. In modern times, most people die of cardiovascular diseases. Some of the most frequent reasons for emergent treatment include myocardial infarction, cardiogenic shock, hypertensive crisis, and metabolic/endocrine causes of coma. Patients may be referred to specialists for treatments or diagnostics, for example, placing a dialysis shunt, specific blood analysis in rheumatic diseases, treatment for thyroid storm, or cancer treatment. Large university hospitals are the exception to this situation. But even here, as we can see in Europe and North America, not all specialty departments exist in one hospital.

Internal medicine has branched into the following areas:

  • Cardiology/Angiology/Pulmonology.
  • Hematology/Oncology.
  • Gastroenterology/Endocrinology.
  • Rheumatology.
  • Nephrology.
  • Emergency medicine/Internal medicine/Intensive care.
  • Occupational medicine.

Hospitals maintain different combinations of these areas. For ex- ample, many departments may combine nephrology and cardiology or gastroenterology and pulmonology. There is an ongoing discussion about the ideal combination of areas, with no conclusion in sight. What actually matters is that patients receive the optimal level of therapeutic and diagnostic care. The patient should be referred to the proper specialty department when the attending department of internal medicine does not have the necessary capabilities to help them.

While specializing in gastroenterology, pulmonology, or oncology, the physician-to-be learns about diseases specific to these areas along with their highly specialized treatment options. In practice, the physician may not see these types of patients every day because such cases may be directly referred from an outpatient clinic to the specialty center. In my assessment it would be useful to complete the training for general internal medicine at a center for basic and regular care, because these centers usually cover the entire spectrum of internal diseases.

Let’s begin with the technical diagnostic methods before moving on to the different sections. In addition to radiographic examinations, which are likely to include thorax imaging as well as CT and MRI, ultrasonography is widely established. Every internist should be able to handle sonographic equipment. In addition, every physician must be capable of interpreting the results obtained via an electrocardiogram (ECG) (Fig. 3.10).

 

Fig. 3.10 ECG showing hemodynamics in severe tricuspid regurgitation with ventricularization of the right atrial pressure wave.

 

Every physician must recognize dysrhythmia, ischemia, and infarction. The diagnostic area of hematology is divided into three sections: morphologic hematology, immunohematology, and hemostaseology. Morphologic hematology involves the microscopic analyses of blood, bone marrow, and smear preparations, as well as biopsies of lymphatic organs. Subtyping of leukemic lymphoma and leukemia is performed via fluorescence-activated cell sorting (FACS). Risk stratification and prognostic assessment are based on cytogenetic methods (genotyping). The main task of immunohematology is human leukocyte antigen (HLA) typing to assess the compatibility assay in organ transplantation. Hemostaseology is focused on the diagnoses of coagulopathies and thrombocytopathies. Therapeutic hematology offers a multilayered spectrum of interventions, including the substitution of coagulation factors, traditional chemotherapy, treatment with biologic agents, and so-called smart drugs that ide- ally facilitate the specific treatment of malignant hematologic systemic diseases.

In the gastroenterology specialty, the student learns about performing gastroscopy, duodenoscopy, endosonographic procedures, colposcopy, and liver biopsy. Pulmonology addresses the use of fiber-optic bronchoscopy, thoracoscopy, and bronchoscopy with and without biopsy sampling. In cardiology, the curriculum includes the use of the following:

  • ECGs and evaluating long-term ECGs.
  • Echocardiography.
  • Ergometry.
  • Pacemaker application.
  • Coronary intervention via stent implantation.
  • Abdominocentesis.
  • Sternal puncture.

Regular participation in radiographic demonstrations and pathologic/ anatomic conferences, interpretations of laboratory test results, and practicing intensive care, which includes the emergency medicine specialty, are also part of internal medicine training. Particularly in the area of internal medicine—aside from diagnostics and the treatment of internal diseases—technical requirements become ever more important.

 

Based on: Introductory Guide to Medical Training
by Manfred G. Krukemeyer

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