Who the patient should firstly address to?

08.09.2022
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Who the patient should firstly address to?

Internal medicine, the "queen of specialties" - as it was formerly called - is indispensable today. We assert this, starting from the definition of this medical specialty. Internal medicine deals with the prevention, diagnosis, and non-surgical treatment of internal organ disorders: lungs, heart, liver, digestive tract, spleen, kidneys, metabolism, joints, and even the bone system. This branch of medicine deals also with the treatment of most diseases affecting adult persons. 

In the modern days, dominated by technological progress and due to some exceptional progress in research, a real conflict of interests has occurred, between the internist, on the one hand, and the over-specialized medical consultant: cardiologist, gastroenterologist, nephrologist, pneumologist, haematologist, etc., on the other hand. These over-specialties, all derived from internal medicine, approach the patient strictly limited to the pathology of the respective organ. But the body must be approached as a unitary whole and an organ cannot be extracted to be investigated, diagnosed, and later treated, omitting any potential pathologies of other organs.

The internal medicine consultant integrates complex cases affecting several organs and establishes the subsequent course for people with multiple pathologies.

If the patient does not know which medical doctor they should address, then it would be advisable to start with a consultation with the internist. Through the consultation offered by the internist, the patient avoids excessive medical consultations that could be not necessary. The internist performs the initial consultation, prescribes the treatment, and if the patient requires additional investigations, he sends him to the appropriate medical consultant (e.g., diabetes has been diagnosed - the patient is guided to the diabetologist, for cancer suspicion - the patient is sent to the surgeon and oncologist, etc.).

When the patient does not know which medical doctor he should address, after the consultation with the family doctor, it is advisable to start with a consultation with the internist. Through the consultation offered by the internist, the patient avoids excessive medical consultations that could be not necessary.

Is internal medicine different from family medicine (or general medicine as it was known until recently)? Here is a question, to which, maybe, even many confreres, would have hesitations to answer. Yes. Definitely, yes. The family physician is the patient's first contact with the health system. The family physician treats the patient in an office. He deals with chronic disorders, immunizations, preventions, and monitoring, according to the recommendations of specialized medical consultants. Once suspicions of serious pathologies occur, that cannot and should not be diagnosed in an office or at home, the family physician has to guide the patient to a polyclinic or to a hospital. The inherent question arises: which specialty should he guide him to? Immediately - the inherent response: to the internist medical doctor.

The internist medical doctor performs the initial consultation, prescribes the treatment, and if the patient requires additional investigations, sends it to the appropriate specialized medical consultant. For example, the patient diagnosed with high blood pressure should no longer address to the cardiologist. The internist medical doctor is empowered to monitor the blood pressure, to recommend the necessary investigations to diagnose possible high blood pressure causes - so-called secondary hypertension, and in the event of diagnosing another disease causing hypertension, only then the patient can, and it is necessary to address to the respective specialty (e.g., nephrology or endocrinology).

The internist medical doctor, having an overview of the various pathologies, from the most common to the most complex ones, is the ablest to elaborate, make associations, discern and rank the priorities, in order to find the real diagnosis of a patient, from the multitude of differential diagnoses determined by certain signs and symptoms, by clinical examination and strictly directed investigations. After the diagnosis, the internist medical doctor will proceed to the effective treatment of the patient, if his pathology is in his area of competence, otherwise, he will guide the patient to the over-specialty corresponding to the diagnosis.

What else does internal medicine deal with? Answer: with the reception and treatment of patients with multiple, serious pathologies, directed by some (over) specialized medical consultants from one to another - cardiologists, nephrologists, diabetes, etc., each reasoning that the treatment of the pathologies related to other specialty is beyond their competence, although, as I have shown above, the body is a unitary whole, which cannot be approached sequentially and isolated. Here comes the major role of the internist medical doctor: to admit in the hospital and treat these patients with complex pathologies, sometimes derived one from another, and each pathology of one organ taken separately, aggravating, or complicating the other/other coexisting diseases (i.e., comorbidities).

As an argument for the above-mentioned, I point out that in the United States, for any of the medical specialties, the residency means 3 years of internal medicine, followed by another 2 years of over-specialization ("Fellowship") in cardiology, gastroenterology, hematology, etc. (called sub-specialties of the internal medicine).

Medical doctor Mariana Mihaila, UMF „Carol Davila”, Medical Clinic - Fundeni Clinical Institute


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