Commentary: Training Internists for Practice Focused on Meeting Patient Needs

The author describes the evolution of practice within the broad specialty of internal medicine. This evolution is driven by scientific discovery, emergent patient needs, and market forces. Four ages describe the evolution: the age of the Oslerian diagnostic consultant, the age of the subspecialist, the age of the primary care internist, and the emerging age of focused general internal medicine practice. The author suggests that competence in practice-based learning and improvement linked with evaluation of practice performance throughout a career permits the professions to abandon the notion that valid learning for medical practice occurs only by completing a designated number of months of residency or fellowship training. By applying competency-based standards for specialty certification and maintaining its validity for current practice, boards can provide trainees and practitioners a tool for professional accountability for initial and continuous professional competence. The lifelong learning and evaluation process permits the timely recognition of proficiency acquired in practice. This process engages internists in ongoing guided reflection on measures of performance and provides evidence that they have incorporated new knowledge, technology, skills, and attitudes that align their practice with patient needs. As dialogue with internal medicine stakeholders and customers continues, the author describes how the training standards for certification might adapt to the evolving demands for the specialty practice and how the evaluation of continuous professional development through the maintenance of certification provides an instrument for identifying and recognizing proficiency in providing focused care within the broad discipline of internal medicine.