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11. The Curious Career of Internal Medicine: Functional Ambivalence, Social Success: One Hundred Years of Internal Medicine
... That plan ensured that postgraduate training in internal medicine would take on the now familiar pattern of generalist internal medicine residency, followed either by generalist practice or by further training leading to subspecialization. 2 The consultant-generalist ideal flourished in internal medicine residency training programs, where residents were able to become familiar with complex cases in all of the subspecialties, training under teachers who were subspecialist in their research but generalist in their clinical work. The monastic life of the internal medicine resident culminated in possible selection as chief resident, a figure in whom the ideal of clinical knowledge that was both wide and deep was perhaps most explicitly valued. ...
American internal medicine suffers a confusion of identity as we enter the 21st century. The subspecialties prosper, although unevenly, and retain varying degrees of connection to their internal medicine roots. General internal medicine, identified with primary care since the 1970s, retains an affinity for its traditional consultant-generalist ideal even as primary care further displaces that ideal. We discuss the origins and importance of the consultant-generalist ideal of internal medicine as exemplified by Osler, and its continued appeal in spite of the predominant role played by clinical science and accompanying subspecialism in determining the academic leadership of American internal medicine since the 1920s. Organizing departmental clinical work along subspecialty lines diminished the importance of the consultant-generalist ideal in academic departments of medicine after 1950. General internists, when they joined the divisions of general internal medicine that appeared in departments of medicine in the 1970s, could sometimes emulate Osler in practicing a general medicine of complexity, but often found themselves in a more limited role doing primary care. As we enter the 21st century, managed care threatens what remains of the Oslerian ideal, both in departments of medicine and in clinical practice. Twenty-first century American internists will have to adjust their conditions of work should they continue to aspire to practice Oslerian internal medicine.
One hundred years ago, in 1909, the American Society for Clinical Investigation (ASCI) held its first annual meeting. The founding members based this new society on a revolutionary approach to research that emphasized newer physiological methods. In 1924 the ASCI started a new journal, the Journal of Clinical Investigation. The ASCI has also held an annual meeting almost every year. The society has long debated who could be a member, with discussions about whether members must be physicians, what sorts of research they could do, and the role of women within the society. The ASCI has also grappled with what else the society should do, especially whether it ought to take a stand on policy issues. ASCI history has reflected changing social, political, and economic contexts, including several wars, concerns about the ethics of biomedical research, massive increases in federal research funding, and an increasingly large and specialized medical environment.
Discussants of internal medicine often invoke but seldom define "the Oslerian tradition," which has many meanings. No definition provides clear insight into the issues now relevant to American internal medicine, primarily because, as William Osler knew, the field itself shows definitional ambivalence. The tradition might be best understood as a virtuous approach to medicine and to life as taught and modeled by Osler. If we understand his philosophy and methods, we will be better prepared to use and pass on (tradere, "to deliver") something of greater value: the ability to make wise choices that are in society's best interest.
The physical improvement, manifested in the average doctor in a few weeks as a result of this training is remarkable. He arrives soft, flabby, often somewhat paunchy, of bad posture, a creature of the automobile era, unable to ride or march. He leaves erect, firm and muscled, well set up and able to do in marching whatever the needs of the service may demand. His waist measure has decreased from 2 to 7 inches, his chest has filled out and in Navy parlance, he has 'shifted his ballast.
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