What kind of a doctor are you?

The occasional general internal medicine recruitment post.

“What kind of a doctor are you?”

“I’m a general internist.”

“Like an intern?”

Laughing, “Don’t you think I’m too old to be an intern? No, I do general internal medicine, mostly outpatient primary care, but I do some inpatient general medicine as well.”

“Oh, so you’re like a GP.”

“Sort of….”

I know, I know, the Sensible Medicine readership does not need an essay on what a general internist does. Consider this another in my occasional series defending my kind, convincing myself of our continued relevance, and maybe tempting (even ever so slightly) some internal medicine resident, medical student, or pre-med to consider my specialty.¹ It has been over a year since I did this last!

It is amazes me how often I must explain what a general internist does. It is enough of an issue that back in the 1990s the American Board of Internal Medicine ran a print advertisement saying that if you knew what this was for, then you needed an internist.²

So what does my kind do? We are outpatient primary care doctors and inpatient generalists – these days, on the inpatient service, we are often working as hospitalists. We are also consultants in both the inpatient and outpatient arena. Inpatient, we often help surgeons manage complex patients during the perioperative period. Outpatient, we often see patients referred to us by capable family medicine doctors and primary care advance practice nurses when they need some help with diagnosis or management.

I’m the “regular doctor” you should probably be seeing if you have a chronic medical problem – or multiple chronic medical problems -- or something that has defied diagnosis or resisted treatment. I’d also be a good person to see if you need to be seen urgently for something more than a cold, or sore throat, or twisted ankle but less than crushing substernal chest pain.³

I don’t do surgery, but I do some procedures in the office. I don’t deliver babies.⁴ I start seeing people as patients when they turn 18 (but, when begged, I’ll sometimes venture as low as 16). So far, my oldest patient has been 106. I am not a dermatologist, urologist, cardiologist, gastroenterologist, chooseyourologist but I care for many of the things they do, and refer to them when I need their help.

Sometimes I am respected as the generalist who knows about everything. Sometimes I am disrespected as the doctor with no specialty: a jack of all trades, master of none; a fox in a field that is increasingly populated by hedgehogs.

During my career I’ve been called a generalist, a PCP, a gatekeeper, a quarterback, and a GP. The gatekeeper is the only one of these terms I loathe because it makes it sound like I am working against the patient, to save money for the insurer, and to protect the subspecialist.

For pretty much any problem you have, a good internist is the right place to start.

If you have shoulder pain, you might go straight to an orthopedist and do terrifically as long as:

1.     your shoulder pain actually originates in your shoulder and is not referred pain from a gallstone, or lung cancer, or esophageal cancer, or a herniated cervical disk, or is an anginal equivalent.

2.     your shoulder pain is a mechanical issue and not an inflammatory one. Polymyalgia rheumatica? Myositis?

3.     the orthopedist is not an overly aggressive one, anxious to take you to the operating room when what you need is six weeks of physical therapy.⁵

4.     the orthopedist is not in the operating room, so you are seeing a physician’s assistant who has been working for 18 months rather than the 20 years your internist has spent evaluating shoulder pain.⁶

5.     you can get in with an orthopedist before your internist can see you, diagnose you, and get you the therapy you need.

I completed a three-year residency, training to take care of the sickest patients, but I now spend most of my time in the office with patients whose sickest days are in their past or future. Here is a day in the office. After niceties, most visits start with one question, “What brings you in?” For a general internist, the possible answers are nearly infinite.

I get pressure in my chest when I mow the lawn.

My wife says I need hearing aids, I think she needs to enunciate.

My shoulder was bothering me until I made the appointment. Now I am not sure why I am here.

I’ve lost my nature.

I can’t fall asleep.

I’m not sure how to tell you this. Last week, I was in the park at a picnic. I really had to pee, so I just went behind a tree. When it hit the ground, the urine created giant pile of bubbles. It’s probably still there. All I could think was to come to the doctor.

Ozempic?

You told me to come back when I saw you last week. Don’t you remember?

What brought me in? Today? The Pace Bus.

I saw blood in sputum.

I saw blood in my semen.

I gave blood and the Red Cross told me that my liver function is abnormal.

I’ve lost 24 pounds over the last three months and now I feel this.

Sounds great, right?

1. It may even prepare you for, say, visiting your brother in law for Thanksgiving whose extended family might not know what you actually do.

2. My parents had the ad on their fridge. They could never be accused of not being proud parents.

3. Of course you can’t see me, because my practice is closed, because I am overwhelmed, because there are too few of us – hence this piece.

4. The last baby I delivered was in the passenger seat of a Saab. That baby is now around 30.

5. Most orthopedists are conservative, thoughtful clinicians who reserve surgery for those who need it most but…

6. There are many profoundly capable PAs and APNs working with orthopedists.