Medicine and the various subjects pertaining to the field did not come to light until Hippocrates entered as a “dogmatical school” (McWharf 47). During this period of medicine, dogmatism was challenged by empiricism, and later by methodism. Dogmatism, the idea of placing rules that are used without contradiction, held its prominence in the field through the works of Galen, his “inhuman[e]” forms of treatment led to the decline of this system of medicine. Consequently, the third period of medicine, rationality dominated the field of medicine. The earliest forms of rationalism in medicine, “from a scientific standpoint,” included the use of treatments made up of excrements, animals, and insects (McWharf 48). This effective use of treatments defined the rationality of the period, a source of rationalization that has influenced the current state and progress of medicine.
What is Rationalization?
According to George Ritzer, American Sociologist, rationalization, or modernly termed as ‘McDonaldization,’ is a process that is based on four dimensions: efficiency, calculability, predictability, and control. The use of each dimension, to a certain extent, rationalizes an institution, a system. Efficiency is being able to optimize a system or method to speed up getting an output from the input . Calculability is the quantitative measure of the output. Predictability emphasizes the idea that a product or output will always remain the same in quality, place, and time. Control is what is being used on what or who benefits from the production.
In the modern- day world, almost all aspects of daily life have been linked to the influence of the process of rationalization.
The Emergence of Internal Medicine
Internal medicine, first named in 1882, was initially known as “special pathology andtherapy,” the intersection between pathology, physiology, and biochemistry (Schulte-Bockolt et al. 480). In the USA, specifically, internal medicine was first termed by the president of the Association of American Physicians (AAP), Dr. William Osler, in 1895. The term was used during a presidential address, “The time has come when able young men should be encouraged to devote themselves to internal medicine as a specialty” (Fordtran et al. 9). Osler proposed to physicians a postgraduate study that emphasized chemistry, physiology, and anatomy, all of which would develop the study of internal medicine. The meaning of “internal medicine” did not define the interior of the body but rather dissecting the illness down to its signs and symptoms by “using the experimental method rather than dogma”. The term, internal medicine, did not have a defined limitation to its practice. Internists had a “less restrictive” environment for the practices of “science, clinical research, and teaching” (10).
The introduction of internal medicine into the medical field during the 20th century increased the efficacy of the diagnosis and treatment of cardiac and gastroenterological diseases, tuberculosis, and allergies. The shift from “experimental physiology and biochemistry” (9) to the common practice of internal medicine allowed for physicians and aspiring- physicians to pursue such interests in a defined field of study or profession. Thus, internists became a specialized, controlled group that practiced the set of skills learned in their now- defined field. The formation of specialties, like internal medicine, led to the need for institutionalized forms of ‘producing’ more specialized physicians.
Educating the First Generations of Internists
Dr. Osler also introduced the first concepts of medical residency training at Johns Hopkins University in 1889. Before, physicians ‘specialized’ by receiving post-graduate degrees (e.g., Ph.D. or D.Sc. degrees), working along with an “established practitioner,” or just by slowly shifting focus into specific fields of medicine. Medical schools during the early 1900s offered limited opportunities for exposure in medical practices, consequently, many physicians studied abroad. But through the work of Dr. Osler and Dr. William Halsted, US surgeon, postgraduate studies moved from a classroom to a clinical setting in hospitals (128). These settings were best- known as “academic hospitals” and their purpose was to teach and research. Furthermore, due to high pursuit of medicine, residency training became normalized and a requirement for specialty physicians (i.e., increasing the predictability of the process).
Certification Check
In 1925, the American College of Physicians (ACP) was formed, and it led to the prominence of the practice specialty internal medicine. Reflecting the Royal College of Physicians of London, it established medical practices and standards that would help improve the healthcare system. Moreover, the prominence of internal medicine and skillful internists increased due to recognition given by the ACP. The growing field of internal medicine required the need for more control over the practice. Therefore, in 1936 the ACP and the American Medical Association organized the formation of the American Board of Internal Medicine (ABIM). The assurance to the public of the criteria upheld by internists increased the predictability of the care given.
Overtime, the ABIM also managed the certification of the subspecialties and sub-subspecialties of internal medicine,, an expansion necessary for further specialized success in the field. The formation of boards and colleges have collectively controlled the development of the field, controlling the foundation of knowledge or skillsets that internists learn from, and the quality of the care given to patients. Virtually increasing the predictability of the process to become an internist and their role in healthcare. The recognition given to internal medicine through the American College of Physicians attracted many physicians to specialize in the field, thereby increasing the number of internists in the US and their availability.
The Next Big Step for Internal Medicine
The proliferation of technological advancements has led to new discoveries within internal medicine, causing an increased demand for internists and physicians in general. Early discoveries like the identification of germs as a cause of disease by Louis Pasteur in 1857 rationalized diagnosis and care for disease- related cases. In the next few decades, Louis Pasteur developed the first vaccines for anthrax and rabies in 1881 and 1882, respectively. Since internal medicine is a mix of several different subspecialties (e.g., immunology, oncology, and cardiology), these anti-viral developments effectively allowed for higher rates of treatment for certain disease and expedited speeds of pinpointing the disease for diagnosing. Another influential development in internal medicine is the invention of the cardiac pacemaker by John Hopps in 1950. Through a surgical procedure, a pacemaker is placed into your body to aid the electrical system of the heart. Now, the use of cardiac pacemakers is common amongst the public. This development in technology in internal medicine led to a more efficient method of helping those with slow heartbeats, or bradycardia. Being a widely used product, these types of pacemakers are produced more and surgically implemented more, therefore increasing its calculability in internal medicine. Furthermore, popular products like these are the “go-to” for internists, which consequently controls the method of treatment used and the care received by the patient. Developments in internal medicine not only became valuable tools to the profession but also influential in the other areas of medicine, becoming a prominent example in medicine.
Internal Medicine at Your Finger Tips
Applications like MedCalc has increased the speed of treatment by providing accurate information on which method to use and how. The implication of these technologies decreases human and random errors in care, essentially increasing the effectivity of the care being provided and the predictability of its routine. One of the various forms technologies has influenced internal medicine is controlling the input and output of information and controlling the methods used to treat a certain case. Digital technology and advanced biosciences have defined modern- day internal medicine. The variety in health applications has helped develop the new set of fundamental tools in internal medicine.
Digital technology and advanced biosciences have defined modern- day internal medicine. The variety in health applications has helped develop the new set of fundamental tools in internal medicine.
Big Data and Precision Medicine
As the timeline of internal medicine- related discoveries continues, such knowledge has accumulated, and it has allowed for internists to effectively predict case- to- case scenarios. The main purpose and use of precision medicine is to “accurately predict outcomes” by considering various predictive variables of different internal diseases and creating a ‘profile’ for individuals (Saracci 250). More than ten million people have contributed to Big Data, each of which have provided to the “accurate prediction” (250) and “quantitative risk of disease determination” (249). The proliferation of predictive tests has led to developing more cost- effective methods for internal care and measurable effective treatment. An example of big data and the use of precision medicine is using “population- based health registries” for internal care- related inquiries (249). Big data has allowed to develop precise, predictable etiological research will fasten the process of diagnosing and treatment for internists. A fundamental factor of precision medicine is its contribution to predictability, outputting trends in risk factors and repeatedly producing precise data for internists. Further developments in amassing data in internal medicine leads to the optimization of the daily routines carried out by internists.
Making a Doctors Life Better
The use of medical scribes in an academic internal medicine practice has led for “improved clinical quality,” expedited processes of fulfilling history of present illness documents (HPI), and lengthened medication review. By using medical scribes in internal medicine practices, internists are given more time to fulfill their duties in diagnosing and treating. One of the inefficiencies of not using medical scribes in such settings is the “potential harm to patients due to missed or misinterpreted information” (Piersa et al. 6). Further positive impacts of medical scribes are increasing clinical times, improving doctor-patient relationships, and “engagement” (7). Medical scribes have contributed to effectively optimizing internal medicine and increasing the calculability of practices by improving essential factors of patient care.
Got Schedule Conflicts?
The implementation of the Automated Internal Medicine Scheduler (AIMS) has positively impacted clinical efficiency and internist satisfaction. Creating schedules for internists is a challenge, one that comes with many consequences that could impede appropriate care and satisfaction. Improved scheduling methods and fairness optimizes the well- being of internists and it increases control over scheduling that could reduce burnout. The well- being of internists is essential to the rationalization of the profession, without them there will be higher rates of irrationalities and diminished care. The first form of a scheduling software was used at Johns Hopkins in 1979, which was used to satisfy staffing and requests for time off. Optimizing the daily routine of an internists allows for them to predict their schedules, have control over it, and increase the effectivity of their care.
The Impurities of a Rationalized Profession
The rationalization of internal medicine increases efficiency, calculability, predictability, and control but it can also pose irrationalities within the field that might impact it negatively. An irrationality means that “rational systems are unreasonable systems… they deny the basic humanity, the human reason, of the people who work within [the profession] or are served by them” (McDonaldization). In internal medicine, and medicine in general, there are two main roles: the giver and the recipient, the internist, and the patient respectively. Changes in a rationalized system or consequences that arise from rationalizations directly impacts these roles and their experiences. Rationalizing internal medicine would mean improving the various aspects of these two roles and increase autonomy but such changes could cause collateral damage: dehumanization, dissatisfaction, improper application of care, non-adherence to regulated guidelines, and limited freedom.
The formation of medical associations, such as the American Board for Internal Medicine and the American Medical Associations, has placed guidelines that limit physician-patient relationships, the conversations they have, and the care the patient receives. A rationalized system that prefers quantity over quality leads to the formation of impersonal relationships and decreased patient satisfaction. Time constraints, placed by the institutions controlling the facility, negatively impacts the doctor-patient relationship as it limits the time to gain trust and knowledge of each other, and it lessens the loyalty of a patient to their internist. The environment of the facility could limit the abilities of an internist to increase the likeliness of a patient to confide in them if the space is not privatized as necessary. Impacts to interpersonal relationships, environment, and routinization redefines the nature of care in internal medicine.
The automatization of internal medicine and the partial loss of control by internists may lead to increased dissatisfaction and loss of internists. High demands on internists have caused for internists to become physically and mentally exhausted. Burnout syndrome “encompasses emotional exhaustion, depersonalization, and reduced personal accomplishment” experienced by those whom have to interact with others in their respective jobs (Guntupalli and Fromm 628). Burnout syndrome can lead to "negative attitudes" and depersonalized manifestations towards a patient (628). Dissatisfaction and depersonalization of internal medicine directly impacts forces of control in internal medicine by producing changes in the morale of internists and therefore influencing them to non-adhere to such forces (e.g., board guidelines, code of ethics, etc.).
The overuse and underuse of care (i.e., high vs low quality care provided) by internists, product of an automatized procedures, has impacted the empiricism and calculability of a rationalized system. A rationalized system is supposed to resolve outside forces affecting the amount or the quality of care provided by internists. But being able to resolve the care of overuse and underuse of care “has been difficult to achieve” (“AMA History”). The methods and autonomy influenced by the forces of rationalization have posed limitations on its output, consequently affecting the quality of care. Calculability, one of the forces of rationalization, affects a profession by routinizing a procedure to hasten ‘production,’ increasing quantity and profits which lack adequate quality. Quality of care is dependent on how a procedure is done and by whom. The institutionalization and creation of board certifications assure patients that their attending internist is well- experienced in the field, therefore increasing the quality of care. But the role of such internist is dependent on the guidelines put in place, thus influencing their methodology and acts.
A United Force
Furthermore, due to the irrationalities explained priorly, some internists have resisted to the changes the forces of rationalization have caused. In a study funded by the American Board of Internal Medicine Foundation, it was explained that a “physicians’ willingness to adhere to clinical practice guidelines” depended on the “subjective norm element” (Ginsburg et al. 669). Therefore, an internists’ decision- making, at times, depends on the specificity of their case and not the guidelines placed by an institution (e.g., ABIM). As a result, these internists show resistance to the control being put in place by a form of rationalization.
Conclusion
Since the introduction of medicine in the Old Kingdom of Ancient Egypt to the emergence of internal medicine as a specialty, this profession has rationalized the medical field through professionalization and institutionalization. The history of internal medicine has repeatedly shown evident forms of rationalization, those that have legitimized the profession as a field and has provided for the care being given today. Given that as the global population increases, there is an increased demand on physicians (e.g., internists), but because of institutionalization, there is a limitation on the output of internists. Even though rationalization is supposed to increase efficiency, calculability, predictability, and control in internal medicine, several irrationalities have raised, affecting the wellbeing of internists and the quality of patient care. Our everyday lives are influenced by these factors no matter the time and place. Moreover, the rationalization of internal medicine is a process that tries to effectively optimize the field, even though collateral consequences might arise. By all counts, the role of internists as caregivers and people is defined by the forces of rationalization, prospering to become essential professionals in our world.
References
AAMC Report Reinforces Mounting Physician Shortage.” AAMC, https://www.aamc.org/news/insights/press-releases/aamc-report-reinforces-mounting-physician-shortage. Accessed 23 Feb. 2022.
Chipidza, Fallon E., et al. “Impact of the Doctor-Patient Relationship.” The Primary Care Companion for CNS Disorders, vol. 17, no. 5, Oct. 2015, p. 10.4088/PCC.15f01840. PubMed Central, https://doi.org/10.4088/PCC.15f01840.
Djulbegovic, Benjamin, et al. “Rational Decision Making in Medicine: Implications for Overuse and Underuse.” Journal of Evaluation in Clinical Practice, vol. 24, no. 3, June 2018, pp. 655–65. PubMed Central, https://doi.org/10.1111/jep.12851.
Fordtran, John S., et al. “The History of Internal Medicine at Baylor University Medical Center,Part 1.” Proceedings (Baylor University. Medical Center), vol. 17, no. 1, Jan. 2004, pp. 9–22.
Ginsburg, Shiphra, et al. “Doing What Might Be ‘Wrong’: Understanding Internists’ Responses toProfessional Challenges.” Academic Medicine, vol. 89, no. 4, Apr. 2014, pp. 664–70. journals.lww.com, https://doi.org/10.1097/ACM.0000000000000163.
Guntupalli, K. K., and R. E. Fromm. “Burnout in the Internist-Intensivist.” Intensive Care Medicine, vol. 22, no. 7, July 1996, pp. 625–30. Springer Link, https://doi.org/10.1007/BF01709737.
Hafner, Katie. “Redefining Medicine With Apps and IPads.” The New York Times, 8 Oct. 2012.NYTimes.com, https://www.nytimes.com/2012/10/09/science/redefining-medicinewith-apps-and-ipads-the-digital-doctor.html.
Hajar, Rachel. “History of Medicine Timeline.” Heart Views : The Official Journal of the Gulf Heart Association, vol. 16, no. 1, 2015, pp. 43–45.
Hough, Douglas E. Irrationality in Health Care: What Behavioral Economics Reveals about What We Do and Why. Stanford University Press, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/unc/detail.action?docID=1180197.
Howard, Frederick M., et al. “Implementation of an Automated Scheduling Tool Improves Schedule Quality and Resident Satisfaction.” PLOS ONE, vol. 15, no. 8, Aug. 2020, p. e0236952. PLoS Journals, https://doi.org/10.1371/journal.pone.0236952.
Howell, Joel D. “A History of Medical Residency.” Reviews in American History, vol. 44, no. 1, 2016, pp. 126–31. Project MUSE, https://doi.org/10.1353/rah.2016.0006.
Landon, Bruce E., et al. “Leaving Medicine: The Consequences of Physician Dissatisfaction.”Medical Care, vol. 44, no. 3, 2006, pp. 234–42.
McDonaldization. https://www.cpp.edu/~ddwills/courses/ant352/readings352/McDonaldization.htm.Accessed 17 Apr. 2022.
McWharf, J. M. “The Early History of Medicine.” Transactions of the Kansas Academy of Science(1903-), vol. 29, 1918, pp. 46–49. JSTOR, https://doi.org/10.2307/3624273.
Piersa, Anastasia Pozdnyakova, et al. “Impact of a Medical Scribe on Clinical Efficiency and
Quality in an Academic General Internal Medicine Practice.” BMC Health ServicesResearch, vol. 21, July 2021, p. 686. PubMed Central, https://doi.org/10.1186/s12913-021-06710-y.
Ritzer, George. The McDonaldization of Society: Into the Digital Age. SAGE Publications, 2020.
Saracci, Rodolfo. “Epidemiology in Wonderland: Big Data and Precision Medicine.” European Journal of Epidemiology, vol. 33, no. 3, 2018, pp. 245–57.
Schnobrich, Daniel J., et al. “Point-of-Care Ultrasound in Internal Medicine: A National Survey of Educational Leadership.” Journal of Graduate Medical Education, vol. 5, no. 3, Sept. 2013, pp. 498–502. PubMed Central, https://doi.org/10.4300/JGME-D-12-00215.1.
Schulte-Bockolt, Arnd, et al. “Internal Medicine in the United States and Germany: Mutual Influences from 1870 to Today.” Wiener Medizinische Wochenschrift, vol. 166, no. 15, Nov. 2016, pp. 479–86. Springer Link, https://doi.org/10.1007/s10354-016-0455-0.
Stewart, M. A. “Effective Physician-Patient Communication and Health Outcomes: A Review.” CMAJ: Canadian Medical Association Journal, vol. 152, no. 9, May 1995, pp. 1423–33.
Wayne, Diane B., et al. “Mastery Learning of Advanced Cardiac Life Support Skills by InternalMedicine Residents Using Simulation Technology and Deliberate Practice.” Journal of General Internal Medicine, vol. 21, no. 3, 2006, pp. 251–56. Wiley Online Library, https://doi.org/10.1111/j.1525-1497.2006.00341.x.
Images Credits
“Enrollment Is Now Open for the Longitudinal Knowledge Assessment.” ABIM, https://www.abim.org/.
“The Elements of Precision Medicine.” Precision Medicine at UCSF, https://precisionmedicine.ucsf.edu/elements-precision-medicine.
Sir William Osler. Oil painting by Harry Herman Salomon after a photograph. Harry Herman Salomon. Wellcome Library, London. Wellcome Images images@wellcome.ac.uk http://wellcomeimages.org Sir William Osler. Oil painting by Harry Herman Salomon after a photograph. Copyrighted work available under Creative Commons Attribution only license CC BY 4.0 http://creativecommons.org/licenses/by/4.0/
Medical staff and female patient. Credit: Wellcome Library, London. and Seeberger Freres. Wellcome Images images@wellcome.ac.uk http://wellcomeimages.org A crowd of medical staff standing round a woman patient in bed in a hospital ward. Murals of foliage and allegories painted on the walls. Photograph 20th century. Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/
Credits:
Created with images by svetavo - "Intensive care unit in the hospital" • Looker_Studio - "Digital transformation change management, internet of things (IoT), new technology bigdata and business process strategy, automate operation, customer service management, cloud computing." • serhiibobyk - "Doctor doing ultrasound diagnosis of lymph node." • Blue Planet Studio - "Project management schedule for business planning. Modern graphic interface showing timeline of each task deadline breakdown in plan to monitor by project manager who manage the overall schedule." • Rawpixel.com - "An elderly patient at the hospital" • etonastenka - "Black people with hands joined. Black people support each other."