Thursday, March 3, 2011

Why Medicine needs Internists


Our system of medicine has morphed into a specialty based top-down interventional phenomenon. An extremely linear approach to the concept that if a disease occurs then the best possible mitigation strategy is to go to the person who has the expertise in that field. While that may be true in specific terms it is not true in general ones. Yes you would need a cardiology interventionalist to place a stent, 
Stent placement in an artery

or an interventional radiologist to place a catheter into the pancreatic duct, or a urologist experienced in the DaVinci Robot system to do Robotic Prostate surgery,
DaVinci Robotics

 but this is not the need of the majority of people who need guidance and management of their bodies as a whole. A generalist or Internist is the best example to provide that service to understand the realm of an individual patient’s care.

This argument might appear simplistic at the surface level, but there is a deeper and sounder basis to it.
Linear Analytics

The linear, predictable argument goes as described above but the non-linear real-world argument shows there is more at stake in the progress of medicine to have a large progeny of the internists in practice then to have specialists.

Don’t get me wrong, the specialists provide specific and very welcome care to patients. I am one of them. But the thinking of the specialist is morphed and grounded in the belief of care from a single vantage point. This is not to say that a cardiologist does not have concern about a patient’s diabetes or that an oncologist does not have an interest in a lung cancer patient’s emphysema, both those events are important from both perspectives and are taken into account in the management of the patient. But, and here is the big but, the thinking is limited to how it impacts the disease being cared for by the specialist. And there, is the rub.

An internist knows the patient as a whole, has an understanding of all his or her physiological array, the various maladies that have ravaged him or her or for that matter based on the patient’s lifestyle what potentialities are in store. The internist is the “hub” that determines the need for a limited or prolonged “spoke” (specialist) engagement between the two and during that period advises both parties of the relevant information that either might forget or misconstrue. In order for the wheel to turn and travel the bumpy road, all information about its limitations and that of the environment must be at hand to all parties.

From a mathematical point of view, the larger the pool of internists the better the optimized collective wisdom within the field of medicine. Alternatively the fractal nature of the chaotic-disconnected specialist system will ultimately undo the good it is meant to do. Based on the mathematical field of “Reductionism,” a large numbers of physician specialists involved in their tightly regimented fields would provide a limited management of the patient as a whole. (Please read Logic of Failure Blog on this site)

In mathematics a field of “Emergence” seems to signify this outline of the “bottom-up” approach where a collective wisdom of a large body of intellect super-cedes the small yet, isolated pockets of “Super-intellect.” This is not to say that specialists are intellectually superior in anyway. Because they are not, they are optimized and adapted to a finite portion of medical facts. An example would be a school of fish that moves as one without a leader but intuitively changes direction to avoid predation, 

just as a large flock of birds swoops down to perch on a tree with reason known only to the collective body.

 An ant colony is not based on a select few ants with super intelligence but thousands of “average ants” that collectively devise the quality of that complex eco-system of an ant colony. 

In this collective system each internist is available to provide and add to the larger insight and therefore progress. Small pockets, relevant only to themselves, do not enhance quality. 
IBM's WATSON playing Jeopardy

A recent technological “wonder” is an excellent example. IBM created a computer with an enormous number of parallel processing chips loaded on to its memory a large library of information to compete with two “champions” of the TV game called “Jeopardy.” Since “Jeopardy” is not only a game of fact based knowledge, it is also a game that exploits the nuance of the question itself, IBM’s WATSON best them by an “intellectual mile.” This underscores the need for a large body of generalists, with the freedom to express their thoughts, to help allow the field of medicine to flourish and thrive. As much as the collective is important, so too is the freedom of expression.

Medicine needs the Internists to thrive. Medicine needs the collective generalist opinion to grow and by doing so, prosper patient management. Medicine needs its internists for its continuing “Emergence.”

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