Evolución de la medicina interna y sus especialidades en las últimas décadas: una mirada al exterior / Evolution of internal medicine and its specialties in last decades: an outward view

RESUMO

The development of the subspecialties of internal medicine in the wetern world is reviewed from a historical perspective, focusing on the case of the United States of America. During the last decades, changes both in society and in medicine as a whole have prompted a great dispersion of medical practice style, not always well-defined in their contents and goals, and ranging from primary care to ultra specialization. The definition of the general internist and of subspecialist together with the atributtes of each category according to, American College of Physicians' task force group are commented upon. Some of the possible reasons accounting for a decreased interest in general internal medicine during the eighties together with figures supporting a recent reversal of this trend are given. New proposals have originated in government as well as in medical circles to promote the development of general internists, conceived as physicians knowledgeable in the classic sunspecialties but also skilled in clinical epidemiology, informatics, behavior medicine, decision-making, clinical economics, ethics and problem solving. ACP, on the other hand, considers that allowing the community-based general internists to disappear, strenghtening the generalists' identity as a primary care-oriented physician who provides no subspecialty care, becoming hospital-based generalists who act mainly as consultants, or becoming fully trained subspecialists who also provide primary care, are all rejectable options. These arguments illustrate the fact that even in highly developed societies a degree of indefinition remains as to best balance between general internal medicine and the subspecialties