The Doctor's Doctor: How To Be An Internist In Five Minutes

Internists are known as the doctor's doctor. The breadth of knowledge for internists is enormous. I often laugh at the computer science folks who do drivebyes on my blog and claim that one day a computer will neatly categorize all illness into neat algorithms and make me expendable. It is simply not possible. As an internist, I manage the whole body. And the evaluation and management I perform on every patient is multi tiered in its breadth and structure. I do this with every patient encounter. All day, every day. If you have five minutes, I'll show you how to do what I do. I interpret my data points across four different organizational structures for every patient, every time. Consistency, consistency, consistency.

• By Organ System. Looking at things by organ system is the first way to conquer disease evaluation and management. Is the disease in the brain? The heart? They thyroid? The lungs? The gallbladder? The bladder? The blood vessels? The blood? The bone marrow? The skin? The neurons? The spinal chord? The colon? The eyes? The hair? The nails? The liver? Disease can affect any organ and an internist's job is to figure out which one.

• By Category of Disease Process. Looking at things by category of disease process is another way an internist must classify the illness. Is it infectious? Is it autoimmune? Is it hormonal? Is it traumatic? Is it genetic? Is it environmental? Is it medication induced? Is it a toxin? Is it allergic? Is it iatrogenic? Is it cancerous? And within each of these categories of disease processes, the internist must ask himself which organ system the disease process is affecting. Is it allergy induced asthma or is it genetic alpha-one antitrypsin induced emphysema. Is it alcohol related cirrhosis or Wilson's disease. Is it myelodysplastic syndrome, a disease of the bone marrow, or is it medication induced pancytopenia. What is the process of the disease?

• Is It Systemic Or Localized? Once you understand the disease process and which organ it affects, you must also know whether the problem is a localized process or a systemic process, and if it is systemic, how else does it present. So much in medicine is lost when you aren't keeping your eyes open. When you focus so strongly on one part of the body and fail to understand the rest. Some infections can be localized in an organ, like an abscess in the liver. Some infections can be systemic and involve multiple organs. Like mononucleosis. Some autoimmune diseases can affect just one organ, like multiple sclerosis and its effect on the neurons of the brain and spinal chord. Other autoimmune diseases, like lupus can span multiple organs, from kidneys and brain to heart and lungs. Lets go back to the cirrhosis example. So it wasn't alcohol related after all. It was hemochromatosis, a genetic disease of iron metabolism that can also affect your skin, joints, pancreas and brain. Is your disease process systemic or localized? Sometimes you find liver disease when your looking for arthritis. It's amazing disease doesn't operate in a cubby hole. And if your disease is a systemic process, you must always be on the look out for its systemic complications.

• Is It Acute Or Chronic? As an internist you want to know if the problem is new or old. Has the patient had heart disease for 25 years, or was it diagnosed last week? Has the patient had diabetes before or is that blood sugar of 350 a new finding? Is that Hgb of 8.9 new or was it there three years ago? Knowing whether something is new or old means all the difference in the world in how you approach it diagnostically. What are you going to do with the information you have in front of you?

What you have here is how I break down every possible illness known to man. Every possible illness can be categorized by organ system, type of disease process, a systemic or localized process and acute or chronic nature. But we aren't done yet. This is just the disease. Full of randomized controlled trials with objective data points. What about the patient? Where do they fall into the loop? Patients don't come to your office complaining of Factor V Leiden. They don't come to your hospital complaining of systemic inflammatory response syndrome. They don't come to your office or hospital complaining of grade II esophageal varices. They come to your office complaining of a swollen leg. They come to your office with dizziness and pain when they pee. They come to your hospital vomiting blood. The goal of all physicians is to try and match the subjective complaints of the patient with the object data points. So you must add in the last component of being an internist

• What Does The Patient Tell You? Are they pointing to one specific point in their belly and saying it hurts right here in my right lower quadrant? Or do they wave their hand over their belly and say it hurts all over? Are they even able to talk? Do they have one complaint? Or a hundred? Do their complaints make sense anatomically? Do they make sense physiologically? Is that pain that jumps from the right leg and makes a right angle turn across the abdomen into the left pinky finger real? Are their complaints believable? Are there too many complaints to believe any of them, the pan positive review of systems? Does mental illness cloud their reality? What the patient tells you can either be diagnostic of a very specific condition or more likely, a generalized constellation of complaints that could be a multitude of disease processes as described above. Great historians are wonderful. Bad historians are painful to work with.

And after the patient has talked with you, Dr Internist, it's your job to try and figure it all out, from the top of the their fro to the bottom of their big toe.
It can be very simple

• I'm coughing, short of breath and have fever and an infiltrate on chest xray which turns out to be a simple pneumonia.

Or it can be something much more complex.

• I'm coughing, short of breath and have fever and an infiltrate on chest xray may in fact be Wegener's granulomatosis, an autoimmune process associated with acute renal failure. It may in fact be a post obstructive infiltrate caused by large lung mass and complicated by an empyema. It may in fact be acute lung injury caused by amiodarone toxicity. It may in fact be tuberculosis. It may in fact be an infarct from a pulmonary embolism. It may be a lot of things.

It may be a lot of things. That's what you can expect from your internist. That's why you should want an internist taking care of you. That's how an internist thinks. That's how they were trained. That's how they manage patients every day of the week. That's why internists won't be replaced with computers. That's why they wont be replaced by extenders. In spite of the folks who say we just need more extenders to manage our health care system. They are not trained to do this type of critical thinking. They do not have the medical foundation or the experience to manage illness through these 4 concurrent stages of evaluation. I know this because I did not fully understand it until the end of my seven year journey to my National Board Exam, which certified my as a physician with expertise in his field of knowledge. A knowledge base you want if you ever get sick.
There you are. That's what your internist does. Every day. That's why the world needs us. Because we have the ability to do something nobody else in the world can. And that is to be the doctor's doctor.

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