Nolan J P
State University of New York at Buffalo, 14215, USA.
Ann Intern Med. 1998 May 15;128(10):857-62. doi: 10.7326/0003-4819-128-10-199805150-00010.
Managed care has substantially changed the environment of health care delivery for general internists and internist-subspecialists. In the current system, one may wonder whether detailed and thoughtful workups still have a role when the direction of medical practice increasingly prizes a high volume of brief encounters. However, the very forces that drive managed care make the role of internist in the care of adults even more central. The internist's unique training and clinical approach should lead to both medically effective and cost-effective health care for adults. This type of health care will be increasingly important as the U.S. population ages and an increasing number of Americans have chronic, multisystem disease. Over the past century, internal medicine has evolved from a consultative model to a discipline that encompasses total adult care, from prevention to diagnosis and treatment of acute and chronic illness and from outpatient care in the office to inpatient care in the intensive care unit. However, the leadership role of internists in the medical care of adults is now being threatened by family medicine and by fragmentation within internal medicine itself. Managed care organizations and the general public must be shown why internists are better able than family physicians to meet the health care needs of adults. Furthermore, as the marketplace becomes more competitive, the issue of when care given by a subspecialist is superior to that given by an internist has become more prominent. The rapidly developing "hospitalist" movement also threatens the traditional role of the internist as the caregiver for adults in health and disease. Given the historic flexibility of internal medicine and the assumption that appropriate roles can be defined for family physicians, subspecialists, and hospitalists, internists will continue to play a central role in providing the best care for adults in the new world of health care delivery.
管理式医疗已极大地改变了普通内科医生和内科亚专科医生的医疗服务环境。在当前体系中，当医疗实践的方向越来越推崇大量简短诊疗时，人们可能会疑惑详细且周全的检查是否仍有作用。然而，推动管理式医疗的这些力量使得内科医生在成人护理中的角色变得更加核心。内科医生独特的培训和临床方法应能为成人提供既有效又具成本效益的医疗服务。随着美国人口老龄化以及越来越多的美国人患有慢性多系统疾病，这种医疗服务将变得愈发重要。在过去的一个世纪里，内科医学已从一种咨询模式演变为一门涵盖成人全面护理的学科，从预防到急慢性疾病的诊断与治疗，从门诊办公室护理到重症监护病房的住院护理。然而，内科医生在成人医疗护理中的领导角色如今正受到家庭医学以及内科医学自身碎片化的威胁。必须向管理式医疗组织和公众说明为何内科医生比家庭医生更有能力满足成人的医疗需求。此外，随着市场竞争愈发激烈，亚专科医生提供的护理何时优于内科医生提供的护理这一问题变得更加突出。迅速发展的“医院医生”运动也威胁到了内科医生作为成人健康与疾病护理者的传统角色。鉴于内科医学历来具有的灵活性以及可以为家庭医生、亚专科医生和医院医生定义适当角色这一假设，在内科医疗服务的新世界中，内科医生将继续在为成人提供最佳护理方面发挥核心作用。
