All internists are at heart a strange mix of both detective and engineer. We are attracted to Internal Medicine in the first place because we are detectives, we want to solve problems, and the problems we want to solve are what makes people sick, because it hurts us when someone suffers, when someone presents with a complex of symptoms that causes them pain. We cannot help ourselves, when faced with someone who is hurting we cannot help but respond, to investigate. “Why is this happening?” we ask ourselves, late at night, laying bed, why? Driving into work early in the morning, while it is still dark, tell me you have not done this; of course you have, you are in Internists. This drives you, it makes you crazy, the not knowing, not able to understand why. This is the heart of an Internist.
But there is another part to your heart, if you are an Internist. This is the part that, when you finally understand the reason for the suffering, you want to attack it, you want to fix it. Once you understand the reason for the problem, you and I cannot rest until it is fixed. This drives us just as much as solving the problem. This is the engineer in us, the part of our heart that cannot stand just recognizing a problem, we have to intervene. I have been on an airplane flying across country with two friends, when someone had chest pain, and us three Internists on the plane were all fighting one another for the chance to take of him. This too makes us crazy, having a problem in front of us that we cannot solve. This too is the heart of the Internist, we are fixers, we are interventionists. But we cannot try to solve every problem that comes across our path, can we? Yes, yes, we can.
Internal Medicine therefore encompasses both the diagnostic work of a medical detective, and the interventional work of an engineer, as we try to rebuild our patients’ health. We want not only to find the piece of the puzzle that fits, we want to put it into place ourselves, and the satisfaction when that piece pops into its place is immense. The reward for fitting that puzzle piece into place is seeing someone get out of the hospital, who would not have gotten out if not for us.
This challenging and diverse skill-set, detecting and engineering, problem solving and fixing, is crucial to the success of all Internists, yet what drives these skills is just as important. If the motivation for these skills is weak, then we will soon become motivated by other, more base things, such as finances, or recognition. These might become the ends, which is dangerous to not just us personally, but to our profession. So why we do something is just as important as what we do, as why we do it will decide what we do in the future, every time we have a dilemma. Our Department carefully guards what motivates us, because it drives what we do, and how well we do it.
Our department is motivated by the twin principles of caring and investigation. These principles not only define who we are as a group, they also drive what we do. We want to hurt when out patients hurt, and feel good when they feel good. When they get out of the hospital we want to rejoice with them. Their victories are our victories. And, we strive to care for not only our patients, but for each other as well. We think that caring for our patients starts with caring for each other, so we value courtesy, kindness, and generosity. We want to not just be professional, but be caring. We also seek not just to be medical technicians, but medical investigators. With every patient and in every situation we are continually striving to discover a better way of doing things, because the status quo is not acceptable. Too many people still die from diseases we do not know how to treat.
It is these two principles that the almost 300 faculty in the department want to convey first and foremost. But we also want to systematically impart medical knowledge to students and trainees. The greatest act of caring for our patients is to ensure that the future generation of physicians will not just reproduce our care, but be better than we are. We have set-up a large medical education group to maximize this, both with inductive and didactic teaching methodologies. We have approximately 190 residents and fellows. We have 16 fellowship programs, many at the cutting edge of medical technology, such as therapeutic endoscopy and hybrid trans-aortic valve replacements. Our fellows have made fundamental contributions not just to patient care, but they have also advanced medical knowledge in their own right. We have developed specific tracks within the residency program, including efforts in hospital medicine, integrative medicine, and global health. Our board pass rate for residents and fellows is nearly unanimous. Our job placement is superb, either in community or academic practice. But what all trainees say is the strength of our department is the collegiality, they feel as if they have made life-long friends here, with which they will stay in relationship the rest of their lives.
We strive to teach trainees to identify the patients’ problems, develop a differential diagnosis, define that diagnosis in an investigative manner, and then plan for treatment, also in an investigative manner. We desire trainees to become even more sensitive and responsive to the needs of patients, which must come first before all other endeavors. This is foundational to our culture of caring. By virtue of becoming physicians, we have made a promise to our patients that we will always care for them, with our hearts as well as our minds. Part of that caring is never accepting the status quo, but always investigating how we can do even little things better. Thus, in our department the nurse administering medication, the tech rooming a patient in clinic or the scheduler booking a patient visit are as much investigators as the scientist in the lab or the principal investigator in a clinical trial. Our trainees serve on the highest committees of the institution, and make fundamental contributions to how we run the medical center, in quality and safety processes, in the format of our EPIC electronic medical record, in the structure of our medical education, and in our early warning systems.
Since one of our cultural pillars is investigation, we work hard at providing every faculty the opportunity to formally ask research questions. Fortunate to have the Gatorade Trust within the Department, we provide a large amount of pilot project funds on an annual basis, in a peer-reviewed manner. We provide substantial bridge support when needed, and have a junior investigator incubator program, where we create inter-disciplinary co-localized teams working on similar pathways but in distinct diseases. We have built a world-class program in mucosal immunology and house the Center for Inflammation and Mucosal Immunology in the Department. Our GI medical oncologists supervise multiple national early phase clinical trials, and our therapeutic endoscopists are leaders in developing novel techniques and devices. We are fortunate to house the Institute for Therapeutic Innovation, a large group of internationally renowned infectious disease experts working on resistant organisms. We have a funded, renowned research efforts in aging, fibromyalgia, lupus, stem cells, genomic instability, obesity and type 2 diabetes, hepatitis, kinase signaling, and hypertension, to name but a few. Our Department is home to many national leaders in specialty medical societies, with board members of the American Society of Hematology, the American Gastroenterologic Association, the American College of Cardiology, and the American Society of Clinical Oncology.
Perhaps most important, our department leads the NIH-funded Clinical and Translational Science Institute, which just moved into a new building on campus. Given all of these remarkable efforts in investigation, our Department has risen into the top third of all departments of internal medicine in NIH funding in just 3 years, indicating the rapid expansion of our investigative enterprise. But federal research funding has been shrinking, and we have become adept at obtaining alternative, non-federal funding, in order to maintain the growth of the research enterprise. We are aggressively transferring our newly discovered technologies to venture capital, as well as birthing multiple small start-up firms, again with the goal of endowing further departmental research.
Internal medicine departments cannot slowly evolve; the health care environment is changing too radically and rapidly, and we need to rethink how we function in such departments. If we are not proactive, change not of our choosing will be forced upon us. Traditional divisional definitions are giving way to trans-divisional disease-centered programs with teams of clinicians and scientists, all investigators, providing care in a local manner. Decentralizing the UF Department of Medicine does not mean less connection within divisions, but rather freedom to decrease barriers, and authority to increase collaboration. We have created many different multi-disciplinary disease-based clinics that are staffed by faculty from several divisions and departments simultaneously. We feel that this is the future of Internal Medicine, where patients are cared for in disease-based medical homes in an inter-disciplinary manner.
Consistent with our culture of caring for each other is the goal of developing personal relationships within the divisions and department. Each disease-based group strives to become a tight-knit team working towards mutually agreed upon goals, and the department is a resource to help them reach that goal. In addition, we seek to make every other department in UF’s College of Medicine better as well, to create shared opportunities for growth.
One of our major goals here is to promote a culture of experimental risk, and enhance collaborative team- and center-based research. There is an inertia, largely based on the addiction of institutions to indirect costs from grants, that subtly alters the ability of the research faculty to take experimental risk. Chairs should promote highly innovative research, research that will actually provide paradigm alterations, open up whole new fields, and ultimately markedly improve the health of patients. Such research is often based on trans-divisional teams, centered on diseases, as mentioned above. Thus, it is even more complex and frustrating to generate, with failure highly possible, but rewards are possible that benefit patient care forever. The goal of our department’s research should not be to plow fields of knowledge, diffusely studying every possible topic, but rather to dig wells, deeply understanding not just phenomena but mechanisms. The research success of our department in the next decade should be measured in major advances in biomedical thought, and changes in medical practice, and not only in quantity of publications and grants.
Finally, our department has a remarkable relationship with UF Health Shands Hospital and the Malcolm Randall VA Medical Center. Our relationship with them is very important to us, and they represent a wonderful patient care, educational, and investigative resource. The basis for this relationship is our shared culture of investigation and caring, both for the ill and for each other. This shared culture has resulted in several of our divisions being ranked in the top-50 by U.S. News & World Report. We are often ranked as the best clinical program in the state of Florida in three specialties – Heart & Heart Surgery, Kidney Disorders, and Pulmonology.
The reason for being for our department is the same as it has been since its founding only a half a century ago, and it remains one of the most noble of all endeavors, which is to systematically relieve human suffering. This underlying desire is never far from the minds of all the members of our department, as it enables us to work through adversity, and provides us direction in the most complex of circumstances.
Robert Hromas, MD, FACP
Chair and Professor
Department of Medicine
University of Florida Health