A tale of two medicines: why India should replace ‘general medicine’ with ‘internal medicine’

Walk into any major teaching hospital in India and look at the signboards. You are likely to find Cardiology, Neurology, Nephrology, Gastroenterology, Endocrinology departments—and, somewhere among them, a General Medicine. Now travel outside India and ask for the corresponding specialty. In most countries and in much of international medical literature, you will be directed to Internal Medicine. Are these two different specialties? No.The Indian ‘general medicine’ physician and the international ‘internal medicine’ physician belong, essentially, to the same broad specialty: the discipline concerned principally with the diagnosis and non-surgical management of disease in adults. The question, therefore, is not whether Indian general medicine is different from internal medicine; it is whether India should continue using a name that has become increasingly ambiguous when a more precise and internationally intelligible name is available.A name that understatesThe first problem is the word ‘general’. To the ordinary patient, a ‘general physician’ can sound like a doctor who treats common ailments—a doctor one sees before being referred to a specialist. But that is not what an MD or DNB physician in General Medicine represents. An internist (one who practices general medicine or internal medicine) has undergone intensive specialist training in the diagnosis and management of complex adult diseases. The internist is expected to integrate information from multiple organ systems, recognise patterns that may not fit neatly into one specialty and manage patients with several simultaneous illnesses.Consider an elderly patient with breathlessness, anaemia, kidney dysfunction, diabetes, weight loss and abnormal liver tests. Which specialist should he be treated by? His condition falls within the specialities of haematology, nephrology, endocrinology and gastroenterology/hepatology -- all of which are sub-specialties of internal medicine in most other parts of the world. But in India they continue to be called super specialties.For our patient with breathlessness, the specialist trained to look at the patient as a whole and ask whether the abnormalities are connected, is the right specialist: an internal medicine consultant. Integrative function is at the heart of internal medicine, and the word ‘general’ does not adequately convey it.General Medicine also creates confusion with Family Medicine. India recognises Family Medicine as a distinct medical specialty. Family Medicine and Internal Medicine are not the same thing. Family Medicine is concerned with comprehensive and continuing healthcare across the lifespan—from children to older adults—and across a broad range of health problems. Internal Medicine, by contrast, is fundamentally the specialist discipline of adult medical care.There is also a common misunderstanding about the word ‘internal’. It does not simply mean ‘medicine of organs inside the body’. The modern concept of internal medicine has deep roots in 19th-century European medicine, particularly German medicine, when advances in physiology, pathology and bacteriology transformed clinical practice. Physicians increasingly applied scientific knowledge to the diagnosis and treatment of diseases that were managed medically rather than surgically. The term ‘Innere Medizin’ emerged from this tradition. Internal medicine, therefore, describes a method and discipline of adult medical practice, not merely a list of internal organs.Why ‘general’ medicine?Why does India say ‘general medicine’ then? The answer lies partly in history. British medicine developed a strong tradition of general clinical medicine. Even as specialisations increased, the general physician retained an important role in British hospitals and broad clinical knowledge remained highly valued. Britain was an important source of the medical terminology inherited by India. There is, therefore, a historical explanation for India’s terminology. The terminology subsequently became part of Indian medical law and was reinforced by Indian institutions. The Indian Medical Council Act of 1956 formally recognised Doctor of Medicine (General Medicine) as a postgraduate medical qualification. By the 1990s, the nomenclature had become even more firmly standardised. The Medical Council of India’s 1993 regulations explicitly stated that the nomenclature for postgraduate degree courses should be uniformly adopted and prescribed M.D in General Medicine. Thus, what may have begun as part of a British medical tradition became entrenched in India’s own regulatory system.Why the nomenclature mattersThe word ‘general’ is increasingly misleading in the age of sub-specialisation. When the term ‘general medicine’ became entrenched, medicine was far less specialised than it is today. Today, internal medicine is the parent discipline from which numerous subspecialties have emerged: cardiology, gastroenterology, nephrology, endocrinology, rheumatology, pulmonology, infectious diseases, haematology, medical oncology and others. The existence of these subspecialties does not make the internist a non-specialist: quite the opposite. The internist’s expertise lies in understanding the patient when disease does not respect these boundaries. That is a specialty in its own right.Indian medicine is no longer operating in an isolated linguistic environment. Indian doctors train abroad; foreign doctors train in India. Indian postgraduate qualifications are evaluated internationally. Medical journals, conferences, guidelines and clinical research operate across national boundaries. A doctor introducing himself or herself internationally as a specialist in internal medicine is immediately understood. The title general medicine may require explanation. That may appear trivial. It is not. Specialty names communicate the scope of a physician’s expertise to patients, colleagues, hospitals, universities, regulators and international institutions. A clear professional vocabulary matters.Formalising usage of an exisiting termThe proposed change would not introduce an alien concept into Indian medicine. The term ‘internal medicine’ is already widely used in Indian hospitals, medical departments, academic literature and postgraduate teaching. The Indian Armed Forces Medical College, for example, has a Department of Internal Medicine. And Indian postgraduate curricula routinely use ‘internal medicine’ to describe the discipline being taught. Even India’s medical regulatory ecosystem is not completely uniform in terminology. The National Medical Commission’s own records contain doctors in general medicine departments whose qualifications are described as M.D., Internal Medicine. The transition, therefore, would not be from an unfamiliar term to a new one. It would be a formal recognition of terminology that is already in partial use.What should change ? The proposal need not be complicated. India could gradually adopt: MD (Internal Medicine) instead of MD (General Medicine); DNB (Internal Medicine) instead of DNB (General Medicine); Department of Internal Medicine instead of Department of General Medicine and Specialist in Internal Medicine or Internist instead of relying on the ambiguous description General Physician. Existing degrees would, of course, remain completely valid. There is no need to alter the training, scope of practice or professional standing of existing physicians. Only the nomenclature would change. A change of name, not a change of specialty. The proposal is therefore not about prestige. It is about precision. It is not about rejecting India’s medical history; it is about allowing medical terminology to evolve with medical practice. Looking aheadEvery profession periodically has to ask whether the language it inherited still accurately describes what it does. Indian medicine has changed enormously since the terminology of its postgraduate specialties was first codified. We now practise medicine in an era of molecular diagnostics, precision medicine, artificial intelligence, genomics, transplantation, complex multisystem disease and unprecedented sub-specialisation. Yet one of our principal adult medical specialties still carries a name that essentially says: general. Perhaps it is time to be more specific.(Dr. Abraham Ittyachen M. is professor of medicine, M.O.S.C Medical College, Kolenchery and chairperson – Association of Physicians of India, Kerala Chapter. abyliz@rediffmail.com)