Important topics in internal Medicine

Differences Between Internal Medicine and General/Family Practice

While they are both primary care doctors and the terms are often used interchangeably internists are not the same as general practitioners and family physicians. One of the key differences is that internists see only adults, and family practitioners see both children and adults.

General Internists

General internists are uniquely qualified to practice primary care and follow patients through their adult lives. Some internists work as hospitalists, delivering primary care in hospital settings; others provide only out-patient care. General internists may also practice in rehabilitation centers and long-term care facilities.

Internal medicine doctors are trained to provide:

• Precise diagnoses of and prompt treatment for a broad range of symptoms and diseases
• Expertise in conditions that affect any of the body's systems
• Guidance, counseling, and preventive interventions for improved overall health
• Life-long comprehensive care and palliative care
• Care for mental health disorders, such as depression and anxiety caused by abnormal activities in the brain, a chronic disease, or hormonal imbalances

General Family Practitioners

Unlike internists, general family practitioners do not solely concentrate on adults and may practice pediatrics, obstetrics, and do minor surgery.

Family physicians can treat a full range of medical issues and provide acute, chronic, and wellness services for patients.

Family physician training involves:

• Adult critical care [1 month]
• Care for children in the hospital or emergency settings [nearly 2 months]
• Geriatric care [1 month]
• Gynecology [1 month]
• In-patient hospital experience [6 months minimum]
• Musculoskeletal medicine [2 months]
• Newborn encounters
• Obstetrics [2 months]
• Surgery [1 month]

Family medicine training also includes behavioral health, common skin diseases, population health, and health system management, wellness, and disease prevention.

Specialized Training

Internists are medical doctors who specialize in preventing, diagnosing, and treating a wide variety of diseases and other health issues that affect adults. They are experts in health promotion, disease prevention, and the care of problems both simple and complex, acute and chronic.

Internal medicine training includes general medical education, as well as time spent rotating among a variety of subspecialty clinics, both in-patient and out-patient.

Internal Medicine Subspecialties

Internal medicine trainees gain experience working in areas that include:

• Endocrinology
• Rheumatology
• Infectious diseases
• Pulmonary diseases
• Cardiovascular diseases
• Critical care medicine
• Hematology
• Oncology
• Gastroenterology
• Nephrology
• Neurology
• Psychiatry
• Dermatology
• Ophthalmology
• Gynecology
• Otorhinolaryngology
• Non-surgical orthopedics
• Palliative medicine
• Sleep medicine
• Geriatrics
• Rehabilitation medicine
  

Internal medicine trainees spend at least one year caring for hospitalized patients, with at least three months in intensive/critical care settings. They undergo hospital-based training for at least one year, with additional exposure to in-patient subspecialties such as cardiology, hematology-oncology, or gastroenterology.
Many internal medicine doctors have a particular subspecialty. To gain expertise for those subspecialties, students complete an additional one to three years of fellowship training after a required three-year internal medicine residency.

Recognized internal medicine subspecialties include:

• Allergy and Immunology [immune system]
• Cardiovascular Disease [heart and vascular system]
• Advanced Heart Failure and Transplant Cardiology
• Interventional Cardiology [heart health]
• Critical Care Medicine [patients with organ system failures]
• Clinical Cardiac Electrophysiology [heart rhythm]
• Endocrinology, Diabetes, and Metabolism [diabetes and other glandular and metabolic disorders]
• Gastroenterology [gastrointestinal system, liver, and gallbladder]
• Transplant Hepatology [liver]
• Hematology [blood]
• Infectious Disease [bacterial, viral, fungal, and parasitic infections]
• Nephrology [kidneys]
• Oncology [cancer]
• Pulmonary Disease [lungs and respiratory system]
• Rheumatology [joints and musculoskeletal system]

Internal Medicine/Body Connection

Internal medicine is the study, diagnosis, and treatment of conditions that affect the internal organs conditions such as heart disease, hypertension, diabetes, obesity, and lung disease. Internal medicine specialists often care for people with complex, chronic, and multisystem disorders.

Based on their subspecialties, internists may work with doctors in other medical specialties or consult on patients referred by another specialist.

Treating a Broad Range of Internal Medicine Conditions

Internal medicine doctors diagnose, manage, and treat a wide range of conditions. These include cancer, infections, and conditions affecting the heart, blood, kidneys, joints, and the digestive, respiratory, and vascular systems. Examples of conditions treated by internists include:

• Abnormal liver biochemical and function tests
• Abnormal uterine bleeding
• Acid peptic disease associated with upper gastrointestinal bleeding
• Acquired thrombotic thrombocytopenic purpura [TTP]
• Acquired von Willebrand syndrome
• Acute aortic dissection
• Acute aortic regurgitation
• Acute bacterial meningitis
• Acute bronchitis
• Acute calculous cholecystitis
• Acute cholangitis
• Acute colonic diverticulitis
• Acute decompensated heart failure
• Acute diverticulitis
• Acute exacerbations of asthma
• Acute ischemic stroke
• Acute liver failure
• Acute lower extremity ischemia
• Acute mesenteric arterial occlusion
• Acute migraine
• Acute myocardial infarction
• Acute pancreatitis
• Acute pericarditis
• Acute pharyngitis
• Acute pulmonary embolism
• Acute respiratory distress syndrome
• Acute sinusitis and rhinosinusitis
• Acute variceal hemorrhage
• Acute viral gastroenteritis
• Adrenal insufficiency
• Airway foreign bodies
• Allergic rhinitis
• Anal fissure
• Angioedema
• Aseptic meningitis
• Aspiration pneumonia
• Atrial fibrillation
• Bacterial brain abscess
• Balanitis and balanoposthitis in children and adolescents
• Bell's palsy
• Bleeding peptic ulcers
• Cancer pain
• Cardiac arrest
• Cardiogenic shock complicating acute myocardial infarction
• Cellulitis and skin abscesses
• Chronic complications and age-related comorbidities in people with hemophilia
• Chronic limb-threatening ischemia
• Clostridial myonecrosis [gas gangrene]
• Clostridioides difficile [C. Diff] infection [formerly Clostridium difficile]
• Cognitive impairment and dementia
• Colonic ischemia
• Constrictive pericarditis
• Convulsive status epilepticus in adults
• Corneal abrasions and corneal foreign bodies
• Cushing's syndrome
• Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults
• Disseminated intravascular coagulation
• Dysphagia in adults
• Electrocardiographic abnormalities suggesting myocardial ischemia and infarction
• Emergency contraception
• Epilepsy and electroencephalogram [EEG]
• Esophageal disease
• Exacerbations of chronic obstructive pulmonary disease [COPD]
• Exercise-associated hyponatremia
• External otitis
• Failed fibrinolysis [thrombolysis] or threatened reocclusion in acute ST-elevation myocardial infarction
• Fasting ketosis and alcoholic ketoacidosis
• Gastrointestinal infections
• Giant-cell arteritis
• Gout flares
• HELLP syndrome [hemolysis, elevated liver enzymes, and low platelets]
• Hepatic encephalopathy
• Hereditary thrombotic thrombocytopenic purpura [TTP]
• Hyperkalemia
• Hypotonic hyponatremia
• Infections of cerebrospinal-fluid shunts and other devices
• Ingested foreign bodies and food impactions in adults
• Intestinal ischemia
• Intracranial epidural abscess
• Invasive group A streptococcal infection and toxic shock syndrome
• Lactic acidosis
• Lower gastrointestinal bleeding
• Lyme disease
• Malignancy-related superior vena cava syndrome
• Massive hemoptysis
• Mechanical colorectal obstruction
• Mechanical small-bowel obstruction
• Mesenteric venous thrombosis
• Metabolic acidosis
• Metabolic acidosis in chronic kidney disease
• Metabolic alkalosis
• Mineral and bone metabolism
• Mitral-valve prolapse and flail mitral leaflet
• Moderate to severe hypertensive retinopathy and hypertensive encephalopathy
• Myopericardial disease
• Narrow QRS complex tachycardias
• Necrotizing soft-tissue infections
• Neoplastic epidural spinal-cord compression
• Neuromuscular disease
• Neuropathies
• New-onset atrial fibrillation
• Non-HIV viral infections
• Non-sustained ventricular tachycardia
• Nonocclusive mesenteric ischemia
• Open-angle glaucoma
• Osmotic demyelination syndrome [ODS] and overly rapid correction of hyponatremia
• Osteonecrosis [avascular necrosis of bone]
• Ovarian and fallopian-tube torsion
• Pelvic inflammatory disease
• Perianal and perirectal abscess
• Peripheral nerve and muscle disease
• Pneumothorax
• Pregnancy complications
• Prerenal disease and acute tubular necrosis in acute kidney injury
• Pulmonary infections
• Retinal detachment
• Rhabdomyolysis
• Right-sided native-valve infective endocarditis
• Second- and third-degree atrioventricular blocks
• Secondary spontaneous pneumothorax
• Segmental colitis associated with diverticulosis
• Severe Crohns disease
• Severe hypovolemia or hypovolemic shock
• Severe ulcerative colitis
• Sickle cell disease
• Simple and mixed acid-base disorders
• Sinus bradycardia
• Spinal epidural abscess
• Spontaneous bacterial peritonitis
• Staphylococcal toxic shock syndrome
• Stevens-Johnson syndrome and toxic epidermal necrolysis
• Streptococcal pharyngitis
• Subacute kidney injury
• Supraventricular arrhythmias after myocardial infarction
• Suspected acute coronary syndrome [myocardial infarction, unstable angina]
• Suspected nephrolithiasis
• Suspected nonvertebral osteomyelitis
• Sustained monomorphic ventricular tachycardia in patients with structural heart disease
• Symptomatic aortic stenosis
• Syncope
• Thoracic aortic aneurysm
• Thyroid storm
• Transient ischemic attack [TIA]
• Tubo-ovarian abscess
• Tumor lysis syndrome
• Unexplained thrombocytopenia
• Unstable angina and non-ST elevation myocardial infarction
• Upper gastrointestinal bleeding
• Urinary tract obstruction and hydronephrosis
• Ventricular arrhythmias
• Ventricular arrhythmias during acute myocardial infarctio
• Vertigo
• Viral encephalitis
• Wide QRS complex tachycardias

Internal Medicine Tests, Procedures, and Surgeries

Internal medicine specialists perform or order tests, procedures, and surgeries based on patients condition, overall health, and wellness goals.

I believe that to a degree we have become too reliant on diagnostic testing, says Aldo Arpaia, MD, a Castle Connolly Top Doctor in Staten Island, New York. An internist with a subspecialty in emergency medicine, Dr. Arpaia is affiliated with Staten Island University Hospital. Thats not to say there arent prudent and timely diagnostic tools at the internists disposal that have value and can improve the quality of care.

These include the OralID® cancer-screening device and non-invasive coronary artery calcium scanning. Coronary artery calcium score testing helps us determine the atherosclerotic load in asymptomatic patients at increased risk for heart disease, says Dr. Arpaia. Calcium scoring can help us to identify and treat at-risk patients more aggressively.

According to Dr. Arpaia, in training his house staff the basic tenet has become known as the Arpaia rule of nines: 90% of your answer comes from a detailed history, 9% from the physical exam and 0.9% from testing.

And with the rise in the incidence of head and neck cancers, internists are on the front lines of oropharyngeal cancer screening. The Centers for Disease Control Prevention [CDC] recommends that all adults 18 and older get screened annually.

Internists as well as nurses and other providers are trained to perform many types of medical procedures, the use of which can vary greatly by specialty, diagnosis, and treatment. Providers need experience and skill and in many cases, additional training and medical credentials to perform these procedures, as well as to minimize patient discomfort, optimize outcomes, and reduce side effects.

Internal medicine specialists commonly perform procedures that include:

• Venipuncture [blood draw] to test blood
• Arterial puncture to analyze blood gases
• Endotracheal intubation
• Flexible sigmoidoscopy
• Intravenous [IV] line insertion
• Nasogastric [NG] tube placement
• Urinary catheters placement

Some internists have been trained in more complex and/or invasive diagnostic and therapeutic procedures, such as thoracentesis, lumbar puncture, and paracentesis.

Categories and other types of tests and procedures an internist might perform include:

• Allergy: Skin testing, rhinoscopy
• Cardiology: Cardiac stress testing, echocardiograms, coronary catheterization, angioplasty, stent insertion, pacemakers, electrophysiology testing and ablation, implantable defibrillators, cardioversion, placement of intra-aortic and intra-ventricular devices
• Endocrinology: Thyroid biopsy, dynamic hormone testing, bone density testing
• Gastroenterology: Upper and lower endoscopy, esophageal manometry, endoscopic retrograde cholangiopancreatography [ERCP], stent insertion, endoscopic ultrasound, liver biopsy
• Hematology/oncology: Bone marrow biopsy, stem cell transplant, lymph node biopsy, plasmapheresis
• Pulmonary: Intubation and ventilator management, bronchoscopy, chest tube thoracostomy, tracheostomy placement
• Renal: Kidney biopsy, dialysis
• Rheumatology: Joint aspiration and therapeutic injection

Internal medicine and many other medical specialties use ultrasound, computed tomography [CT], and magnetic resonance imaging [MRI] to guide invasive procedures. Flexible fiberoptic instruments may be used to access hard-to-reach areas of the body.

Major Professional Societies for Internal Medicine

Major professional societies for internists include:

• Alliance for Academic Internal Medicine
• American Association of the Study of Liver Diseases
• American College of Cardiology
• American College of Gastroenterology
• American College of Physicians [ACP]
• American Diabetes Association
• American Geriatrics Society
• American Heart Association
• American Medical Association
• American Society of Gastrointestinal Endoscopy
• American Society of Hematology
• American Thoracic Society
• Endocrine Society
• Infectious Diseases Society of America

Breaking News and Information on Internal Medicine

There are new advances in internal medicine all of the time. This includes new medications and types of surgery that improve how internists can help their patients. Because of this, its important to stay up to date on the latest news. Here are a few reliable websites where you can stay current on the latest news and information within internal medicine:

• Annals of Internal Medicine
• ACP Internist
• ACP Gastroenterology Monthly
• ACP Diabetes Monthly
• ACP Hospitalist
• American Journal of Medicine
• American Journal of Physical Medicine and Rehabilitation
• Archives of Physical Medicine and Rehabilitation
• BMC Medicine
• British Journal of Medical Practitioners
• Cleveland Clinic Journal of Medicine
• Clinical Medicine & Research
• Journal of Clinical Epidemiology
• Journal of Internal Medicine
• New England Journal of Medicine

Q&A with Aldo Arpaia, MD

Aldo Arpaia, MD, is a Castle Connolly Top Doctor in Staten Island, New York. An internal medicine doctor who subspecializes in emergency medicine, Dr. Arpaia is affiliated with Staten Island University Hospital.

Q: How do you encourage people to make lifestyle adjustments that will improve their present and future health?
A: I believe it starts with getting patients to understand and buy in to important lifestyle changes and trying to reinforce that at every visit.

As for things people can do to improve their present and future health, diet, exercise, and statin therapy where indicated can help slow the progression of coronary artery disease. An active lifestyle does indeed improve outcomes, as does refraining from tobacco and excessive alcohol use. Patients under 45 should consider being vaccinated against human papillomavirus [HPV].

Q: Who should be on a persons health team besides an internist?
A: Its important that patients have on their health teams specialists appropriate to their specific health needs. Women, for example, should have a gynecologist, while someone with diabetes should have an endocrinologist.