Learning outcomes
- 1.
Describe the practice of internal medicine.
- 2.
Define the role of the physician assistant student on an internal medicine rotation.
- 3.
Describe the challenges and rewards of practicing in internal medicine.
Introduction
Internal medicine is a medical specialty that provides comprehensive health care to adult patients. This includes health prevention and the management of complex acute and chronic diseases. The nature of the practice of internal medicine allows health care providers to establish a long-term relationship with patients. Providers have the opportunity to be involved in all aspects of medical care, offering patients ongoing care for many years. Medical care most commonly takes place in an ambulatory outpatient clinic but can also include inpatient care during hospitalizations and in skilled nursing facilities.
Upon completing a 3-year residency in internal medicine, physicians are referred to as “internists” and practice general internal medicine. A hospitalist is a physician trained in internal medicine, whose primary focus is on caring for hospitalized patients. Subspecialists in internal medicine complete the 3-year residency and then a 2- or 3-year fellowship in an area of interest, such as allergy and immunology, cardiology, endocrinology, gastroenterology, geriatrics, hematology, or oncology.
Physician assistants (PAs) with a strong interest in internal medicine may choose to broaden their knowledge base by enrolling in a postgraduate residency program. These programs are offered by medical institutions and are commonly 12 months in duration. Upon completion of a residency, the PA will receive a certificate indicating the completion of the postgraduate training in internal medicine.
Physician assistants in internal medicine
PAs in internal medicine can expect to encounter a broad range of health issues. Patients may present with health conditions that are relatively simple and straightforward, but other issues can be complex and involve multisystem disease processes. Preventive medicine is an important aspect of the practice of internal medicine and includes the promotion of a healthy lifestyle and the prevention of chronic illnesses, such as diabetes mellitus, cardiovascular disease, and cancer.
Practice settings for internal medicine PAs range from ambulatory outpatient clinics and hospitals to long-term skilled care facilities. Practicing in these different environments is advantageous because it allows the PA to follow a patient through a continuum of care. Continuity of care is essential to maintaining quality and consistency in dealing with chronic disease.
PAs in general internal medicine can expect an average annual base salary of $88,000 to $132,000 depending on multiple factors, such as years of practice and geographic location. Compensation packages and benefits depend on the institution or practice.
Physician assistants in internal medicine subspecialties
In addition to general internal medicine, PAs commonly practice in one of the 13 internal medicine subspecialties. According to the 2018 National Commission on Certification of Physician Assistants Statistical Profile of Certified Physician Assistants, of the survey respondents, 9.5% ( n = 9,877) indicated that they practiced in one of the internal medicine subspecialties. PAs in one of the subspecialties can expect a similar base salary to that of general internal medicine. This information can be accessed through the American Academy of Physician Assistant (AAPA) Salary Report, which is published annually by the AAPA.
Internal medicine rotation
The general internal medicine rotation offers PA students the opportunity to expand their knowledge both regarding common acute and chronic illnesses in adult patients and screening and preventive medicine. The rotation broadens the depth and breadth of the student’s medical knowledge base about the disease process and the pharmacotherapeutics used in the management of disease. The rotation reinforces clinical skills in patient interviewing; physical examination; and interpretation of ancillary testing, case presentations, and detailed written documentation. The student benefits from working in a team-based environment while using clinical reasoning skills. The rotation assists the student in developing skills necessary to assess clinical situations accurately, develop a differential diagnosis list, and arrive at a working diagnosis. The clinical experiences may be outpatient based or hospital based or a combination of both environments.
What to expect and know
Expectations and student responsibilities depend on the rotation site and the preceptor. Generally speaking, the PA student should have basic knowledge of a broad spectrum of acute and chronic illnesses and be a self-directed learner. The student should be able to perform a thorough patient history and comprehensive physical examination confidently. The development of a concise differential diagnosis list based on the history and physical examination will guide the student in ordering and interpreting the appropriate diagnostic tests. The PA student will formulate an assessment, plan, and the appropriate patient education and follow-up. Each case is presented to the preceptor by clearly identifying the patient’s chief complaint, history, pertinent physical examination findings, assessment, plan, and follow-up. The presentation needs to be well organized and provide the preceptor with the essential information regarding the patient encounter. The student should be prepared to answer questions about each case and ask appropriate questions of the preceptor to augment the learning experience. At the conclusion of an internal medicine rotation, the student should gain broader knowledge of the pathophysiology of acute and chronic disease, improve his or her skills in developing a comprehensive differential diagnosis list, confidently order and interpret diagnostic testing, and have a solid understanding of the role of pharmacotherapeutics in the management of disease.
Clinical environment
Practice settings for PAs in internal medicine range from outpatient clinics to hospitals, skilled nursing facilities, or a combination of all. The job of the PA in the inpatient setting is to care for patients who are typically acutely ill. It requires the PA to participate in daily rounds on the patients, either independently or as part of a multidisciplinary health team. Effective organizational skills are essential in managing multiple hospitalized patients. It can be helpful to develop a system for keeping patient data at your fingertips. It may be the responsibility of the PA to perform the initial complete history and physical examination on all newly admitted patients. This information must be meticulously gathered because it may affect the initial management of a patient. The role of the PA in the hospital setting may include direct communication with patients and their families. It is important for PAs to feel comfortable and confident when discussing all aspects of the management of hospitalized patients.
Many PAs in internal medicine, especially in smaller communities, care for patients residing in skilled nursing facilities. This may require the PA to round on patients and manage their care through effective communication with the nursing staff, patients, and, many times, families. In certain situations, nursing home patients are transported to the outpatient clinic for routine care. A patient may not have a family member accompanying him or her or may have difficulty with verbal communication, so it is important that written orders for the nursing staff at the facility are clear and concise.
The ambulatory clinic setting requires the ability to work autonomously while using critical thinking skills in the assessment and management of disease. Time management, organizational skills, and the ability to think on your feet are vital in the outpatient clinic setting.
Other health professionals
In addition to internists, PAs work with a multidisciplinary team of health professionals in internal medicine. These individuals play a significant role in the effective care of the patient; therefore it is important to have the ability to work well with a team. Internal medicine PAs often collaborate with primary care providers, internal medicine subspecialists, surgeons, physical therapists, pharmacists, nurses, and social workers, among others. It is essential to understand the role of each member of the health team and to be able to communicate effectively with these individuals to provide the best care possible for patients.
Patients and special populations
PA students and PAs practicing in general internal medicine or one of the internal medicine subspecialties are exposed to a variety of adult patients with a broad range of backgrounds, medical issues, and socioeconomic concerns. Many of these patients may have multiple health conditions, which can result in functional limitations that require supportive services to assist with daily care or transportation. Decreased hearing and visual acuity can make patient-provider communication a challenge. Patients with a diagnosis of dementia are common in an internal medicine practice and performing a history and physical examination takes time and patience. Many geriatric patients live on a fixed income, which can influence their ability to afford medications or diagnostic testing. The internal medicine environment allows providers to practice many aspects of medicine and to care for a diverse group of patients.
Challenges and rewards
Practicing in internal medicine comes with both challenges and rewards. Patients present with multisystem disease states that can be complex and at times overwhelming. A good clinician must have excellent problem-solving skills and the insight to pursue lifelong self-directed learning. Caring for adults requires patience and empathy but is rewarded with patient trust. As a PA, the practice of internal medicine can potentially be very rewarding because of these deeply rooted patient–provider relationships that develop over time. It is common to care for different generations of the same family line. Providers in internal medicine develop relationships with patients based on trust, confidentiality, and professionalism. Patient–provider relationships many times last until the end of life.
