Внутренняя медицина: специализация и история развития

Medical specialty dealing with adult diseases

Internal medicine, also known as general internal medicine in Commonwealth nations, is a medical specialty for medical doctors focused on the prevention, diagnosis, and treatment of internal diseases in adults. Medical practitioners of internal medicine are referred to as internists, or physicians in Commonwealth nations. Internists possess specialized skills in managing patients with undifferentiated or multi system disease processes. They provide care to both hospitalized (inpatient) and ambulatory (outpatient) patients and often contribute significantly to teaching and research. Internists are qualified physicians who have undergone postgraduate training in internal medicine, and should not be confused with "interns", a term commonly used for a medical doctor who has obtained a medical degree but does not yet have a license to practice medicine unsupervised. In the United States and Commonwealth nations, there is often confusion between internal medicine and family medicine, with people mistakenly considering them equivalent. Internists primarily work in hospitals, as their patients are frequently seriously ill or require extensive medical tests. Internists often have subspecialty interests in diseases affecting particular organs or organ systems. The certification process and available subspecialties may vary across different countries. Additionally, internal medicine is recognized as a specialty within clinical pharmacy and veterinary medicine.

[[File:Robert Koch. jpg|thumb|206x206px|Robert Koch, 19th century German physician and microbiologist Sydenham emphasized understanding the internal mechanisms and causes of symptoms rather than dissecting cadavers and scrutinizing the internal workings of the body. In the 17th century, there was a shift towards anatomical pathology and laboratory studies, and Giovanni Battista Morgagni, an Italian anatomist of the 18th century, is considered the father of anatomical pathology. Laboratory investigations gained increasing significance, with contributions from physicians like German physician and bacteriologist Robert Koch in the 19th century. During this time, internal medicine emerged as a field that integrated the clinical approach with the use of investigations. Many American physicians of the early 20th century studied medicine in Germany and introduced this medical field to the United States, adopting the name "internal medicine" in imitation of the existing German term. Internal medicine has historical roots in ancient India and ancient China. The earliest texts about internal medicine can be found in the Ayurvedic anthologies of Charaka.

Internal medicine specialists, also referred to as general internal medicine specialists or general medicine physicians in Commonwealth countries, are specialized physicians trained to manage complex or multisystem disease conditions that single organ specialists may not be equipped to handle. They are often called upon to address undifferentiated presentations that do not fit neatly within the scope of a single organ specialty, such as shortness of breath, fatigue, weight loss, chest pain, confusion, or alterations in conscious state. Although internists may serve as primary care physicians, they are not synonymous with "family physicians," "family practitioners," "general practitioners," or "GPs." The training of internists is solely focused on adults and does not typically include surgery, obstetrics, or pediatrics. According to the American College of Physicians, internists are defined as "physicians who specialize in the prevention, detection, and treatment of illnesses in adults." While there may be some overlap in the patient population served by both internal medicine and family medicine physicians, internists primarily focus on adult care with an emphasis on diagnosis, whereas family medicine incorporates a holistic approach to care for the entire family unit. Internists also receive substantial training in various recognized subspecialties within the field and are experienced in both inpatient and outpatient settings. On the other hand, family medicine physicians receive education covering a wide range of conditions and typically train in an outpatient setting with less exposure to hospital settings. The historical roots of internal medicine can be traced back to the incorporation of scientific principles into medical practice in the 1800s, while family medicine emerged as part of the primary care movement in the 1960s.

The training and career pathways for internists vary considerably across different countries. Many programs require previous undergraduate education prior to medical school admission. This "pre medical" education is typically four or five years in length. Graduate medical education programs vary in length by country. Medical education programs are tertiary level courses, undertaken at a medical school attached to a university. In the US, medical school consists of four years. Hence, gaining a basic medical education may typically take eight years, depending on jurisdiction and university. Following completion of entry level training, newly graduated medical practitioners are often required to undertake a period of supervised practice before their licensure, or registration, is granted, typically one or two years. This period may be referred to as "internship", "conditional registration", or "foundation programme". Then, doctors may follow specialty training in internal medicine if they wish, typically being selected to training programs through competition. In North America, this period of postgraduate training is referred to as residency training, followed by an optional fellowship if the internist decides to train in a subspecialty. In most countries, residency training for internal medicine lasts three years and centers on secondary and tertiary levels of health care, as opposed to primary health care. In Commonwealth countries, trainees are often called senior house officers for four years after the completion of their medical degree (foundation and core years). After this period, they are able to advance to registrar grade when they undergo a compulsory subspecialty training (including acute internal medicine or a dual subspecialty including internal medicine). This latter stage of training is achieved through competition rather than just by yearly progress as the first years of postgraduate training.

In the US, three organizations are responsible for the certification of trained internists (i. e., doctors who have completed an accredited residency training program) in terms of their knowledge, skills, and attitudes that are essential for patient care: the American Board of Internal Medicine, the American Osteopathic Board of Internal Medicine and the Board of Certification in Internal Medicine. The Royal Australasian College of Physicians confers fellowship to internists (and sub specialists) in Australia. The Medical Council of Canada oversees licensing of internists in Canada.

In the US, two organizations are responsible for certification of subspecialists within the field: the American Board of Internal Medicine and the American Osteopathic Board of Internal Medicine. Physicians (not only internists) who successfully pass board exams receive "board certified" status.

After completing medical school, internists in Canada require an additional four years of training. Internists desiring to subspecialize are required to complete two additional years of training that may begin after the third year of internist training. The Royal College of Physicians and Surgeons of Canada (RCPSC) is a national non profit agency that oversees and accredits medical education in Canada. A full medical license in Internal Medicine in Canada requires a medical degree, a license from the Medical Council of Canada, completion of the required post graduate education, and certification from the RCPSC. Internists may work in many settings including outpatient clinics, inpatient wards, critical care units, and emergency departments. The currently recognized subspecialties include the following:

Determining which pieces of information are most important to the next phase of the diagnostic process is of vital importance. It is during this stage that clinical bias like anchoring or premature closure may be introduced. Once key findings are determined, they are compared to profiles of possible diseases. These profiles include findings that are typically associated with the disease and are based on the likelihood that someone with the disease has a particular symptom. A list of potential diagnoses is termed the "differential diagnosis" for the patient and is typically ordered from most likely to least likely, with special attention given to those conditions that have dire consequences for the patient if they were missed. Epidemiology and endemic conditions are also considered in creating and evaluating the list of diagnoses. The list is dynamic and changes as the physician obtains additional information that makes a condition more ("rule in") or less ("rule out") likely based on the disease profile. The list is used to determine what information will be acquired next, including which diagnostic test or imaging modality to order. The selection of tests is also based on the physician's knowledge of the specificity and sensitivity of a particular test. An important part of this process is knowledge of the various ways that a disease can present in a patient. This knowledge is gathered and shared to add to the database of disease profiles used by physicians. This is especially important in rare diseases.

Communication is a vital part of the diagnostic process. The Internist uses both synchronous and asynchronous communication with other members of the medical care team, including other internists, radiologists, specialists, and laboratory technicians. Tools to evaluate teamwork exist and have been employed in multiple settings. Communication to the patient is also important to ensure there is informed consent and shared decision making throughout the diagnostic process.

Treatment modalities generally include both pharmacological and non pharmacological, depending on the primary diagnosis. Additional treatment options include referral to specialist care including physical therapy and rehabilitation. Treatment recommendations differ in the acute inpatient and outpatient settings. Continuity of care and long term follow up is crucial in successful patient outcomes.

Aside from diagnosing and treating acute conditions, the Internist may also assess disease risk and recommend preventive screening and intervention. Some of the tools available to the Internist include genetic evaluation. Internists also routinely provide pre operative medical evaluations including individualized assessment and communication of operative risk. Training the next generation of internists is an important part of the profession. As mentioned above, post graduate medical education is provided by licensed physicians as part of accredited education programs that are usually affiliated with teaching hospitals. Studies show that there are no differences in patient outcomes in teaching versus non teaching facilities. Medical research is an important part of most post graduate education programs, and many licensed physicians continue to be involved in research activities after completing post graduate training.

Inherent in any medical profession are legal and ethical considerations. Specific laws vary by jurisdiction and may or may not be congruent with ethical considerations. Thus, a strong ethical foundation is paramount to any medical profession. Medical ethics guidelines in the Western world typically follow four principles including beneficence, non maleficence, patient autonomy, and justice.

The relationship is built upon the physician obligations of competency, respect for the patient, and appropriate referrals while the patient requirements include decision making and provides or withdraws consent for any treatment plan. Good communication is key to a strong relationship but has ethical considerations as well, including proper use of electronic communication and clear documentation.

Providing treatment including prescribing medications based on remote information gathering without a proper established relationship is not accepted as good practice with few exceptions. These exceptions include cross coverage within a practice and certain public health urgent or emergent issues. however, with appropriate use and specific guidelines, risks may be minimized and the benefits including increased access to care may be realized.

Other foundational ethical considerations include privacy, confidentiality, accurate and complete medical records, electronic health records, disclosure, and informed decision making and consent. Withholding information from a patient is typically seen as unethical and in violation of a patient's right to make informed decisions. However, in situations where a patient has requested not to be informed or to have the information provided to a second party or in an emergency situation in which the patient does not have decision making capacity, withholding information may be appropriate.