Speaking to patients as well as personal friends, I have become aware that many people do not fully understand what an Internal Medicine physician really does. Simply put, we are the broadest specialty that diagnoses and manages adult health problems. We are not interns-- an intern is a first year resident. We are also not General Practitioners (GP). General Practitioners are at this point mostly a remote part of medical history. Technically, a physician may become a general practitioner if he or she finishes one year of residency after medical school and then becomes licensed as a physician. An internist is a physician whose medical specialty focuses on the prevention, diagnosis, and treatment of adult diseases. One description of Internal Medicine that resonates best with patients is the analogy that Internists are "Pediatricians for Adults".

The term Internal Medicine comes from the German name Innere Medizin (pronounced in-'err-a med-i-tzeen'), popularized in Germany 100 years ago to describe physicians who combined the science of the laboratory with the care of patients. Many early 20th Century American doctors studied medicine in Germany and brought this new field-which married scientific discovery with the healing art-to the U.S. They adopted the name Internal Medicine. Like some words adopted from other languages, it doesn't fit any American meaning. This is likely why there is so much confusion around an Internist. We are one of three specialties in the area known as Primary Care- the other two being Pediatrics and Family Medicine. Primary care physicians can be viewed as personal health care advisers for patients. We function as physicians who guide patients through the complex system of modern health care services. Modern health care services include preventive services such as vaccinations, referring to other specialists, assisting in getting admitted to the hospital, coordinating prescriptions, as well as coordinating home health care and access to durable medical equipment.

On any given day I wear multiple medical "hats". My first appointment might involve a health physical where I am making sure a patient has had all the proper vaccinations and is getting cancer screening and not developing the most common of adult silent illnesses such as obesity, hypertension or diabetes. In that first room the patient's complaint of new scaling skin lesions may require that I be a Dermatologist and diagnose and perhaps treat the problem. In the next room a patient may be complaining of cough and sputum changes, which falls in the field of Pulmonary Medicine. My third appointment may involve complaints related to the heart system and thus on goes my Cardiology "hat". Many times in a single visit, I may wear 2, 3, or even four different physician "hats". The above described typical day illustrates why my field is called General Internal Medicine. I see, evaluate and manage many general/common adult health problems.

Let me discuss the path one takes in order to become an Internist.  Upon graduating from medical school, you will spend three years of post-graduate training in an Internal Medicine residency program.  During this time, you serve as an MD under the guidance of Attending Physicians.  This consists of rotations in various subspecialties, critical care units, as well as outpatient clinics.  There are many subspecialties which people are familiar with that come from within the field of Internal Medicine. Examples include: Pulmonary and Critical Care, Endocrinology, Nephrology, Rheumatology, Gastroenterology, Cardiology, Hematology/Oncology, and Infectious Disease. All of the mentioned specialties were first trained as General Internists. After taking their Internal Medicine Board exams, they subsequently went on and trained between 2-4 years of additional fellowship training in their particular subspecialty. When I trained in Internal Medicine, I spent at least one month working side-by-side with a specialist in all the above-mentioned fields.

As a patient, if you are thinking you might need a subspecialist such as a cardiologist, I wish for you to understand that your general Internist has significant training, exposure, and medical knowledge in that field. The Cardiology subspecialist went on to become more intensely exposed to cardiac conditions and specifically cardiologists learned interventional techniques as related to cardiovascular disease diagnosis and management. For the common subspecialty conditions, an Internist is fully capable of managing the problem. As an Internist, I view the need for the subspecialist as necessary when specific diagnostic procedures or treatment plans that are unique, new, or unusual to that particular field are needed to manage a medical problem. Patients often have more than one medical condition that falls within the various subspecialties. Again it is best to be managed by a general Internal Medicine physician who has general subspecialty knowledge and is capable of using medications from the various specialties. This is where the "quarterback" function of your Internist is highlighted.

Doctors themselves often refer to the Internist as the "Doctor's Doctor." Internists tend to be the "detectives of health" and are known for their diagnostic skills. If a person has an unusual or difficult medical problem that perhaps no one has yet labeled, they are best served by seeing an Internist. As your Internist the physicians of Internal Medicine of Southwest Florida are your "go to" quarterbacks. Unless you have suffered an obvious trauma, I recommend you call upon me and my colleagues to evaluate any ailment you may develop. By starting with an Internist you can be effectively diagnosed and moved through the complex health care system efficiently. I recommend that the average patient does not try to self refer to a specialist based upon a particular physical complaint. Since the human body is very complex, people may have various symptoms and complaints related to various diseases. If you send yourself to a neurologist when in fact you need a neurosurgeon, you have wasted important time as well as money and physician resources. If your cough happens to be related to a cardiac condition but you assumed it is a lung problem, your self-made referral to a Pulmonary Specialist might result in delayed treatment or improper diagnosis.

Many patients do not understand the wide skill set that Internal Medicine physicians have. Depending upon an Internal Medicine physician's training and procedural experience, we are often are able to manage a large majority of things that are also seen by subspecialists. As an example, I am very comfortable providing cryotherapy to premalignant and early malignant skin cancers. I provide injections to large joints such as the knee and shoulder, and all of us in our group supervise and interpret EKG's and cardiac stress tests. When it comes to musculoskeletal disorders, our patients are often surprised that we can coordinate diagnostic imaging such as MRI if necessary and appropriate. In the majority of cases musculoskeletal complaints are best remedied with conservative management such as stretching and/or physical therapy. Our electronic medical record system provides very useful handouts that provide information and illustrations for patients to begin taking care of their problem at home. If our conservative recommendations fail or a person's pain is so acute that they need more hands-on assistance, we can readily refer them to independent physical or occupational therapists. This approach is a more effective utilization of our health care system and helps reduce the burden on our specialists in the areas of orthopedics and neurosurgery.

The price of an Internal Medicine office assessment offers terrific value. An Internist can diagnosis and manage a multitude of medical conditions that technically fall into the field of numerous subspecialties but quite frankly don't require a subspecialist level of expertise to manage (in the majority of cases). I encouraged our readers to visit our website and specifically look at the services we provide to get a better idea of what an Internal Medicine physician is capable of.  All of the physicians of Internal Medicine of Southwest Florida are board-certified by the American Board of Internal Medicine. Dr. Kordonowy is also board-certified in clinical lipidology  

Alcohol and Caffeine

At Opposite Ends of the Pole

Author Tom Standage states his in his book,  A History of the World in 6 Glasses , " ...Coffee came to be regarded as the very antithesis of alcohol, sobering rather than intoxicating, heightening perception rather than dulling the senses and blotting out reality". This book gives an historical review of beer, wine, high spirits, coffee, tea, and Coca-Cola.

In our modern times alcohol continues to be a focal point for social interaction and personal enjoyment, while caffeine in its various forms continues to be the "success drink". In the United States, caffeine is mostly consumed in the form of coffee--although my wife is constantly frustrated at local restaurants as they rarely offer tea, her preferred caffeinated beverage.

Drinking alcohol in moderation appears to be very healthy. I am sure every American knows someone who has suffered directly or indirectly from the disease alcoholism. Most patients I interview consume modest amounts of alcohol on a regular basis. By modest consumption I mean 1-4 alcoholic beverages several times a week, if not daily. When I first started practicing medicine I felt this seemed to be a large amount of drinking. However, during my medical career there have been numerous articles that indicate this amount of alcohol intake reduces cardiovascular mortality and overall mortality. I am left to conclude that as long as a person is not driving under the influence of alcohol or suffering direct alcohol related organ damage and has no social or family problems related to drinking I have no reason to criticize its consumption.

Alcohol is a source of calories. I have frequently counseled persons who are  having weight issues that they should consider reducing or eliminating alcohol intake if they're trying to lose weight. I've written in the past about the health risks of obesity and its relationship to the epidemic of adult onset diabetes in America in the world as well. Nutritionally, 1 gram of ethanol is approximately 7.1 calories and a typical drink contains between 70 and 100 calories from a combination of ethanol and carbohydrates. Normally when physicians or dietitians speak of calories we typically are speaking about protein, carbohydrate, and fat. One gram of carbohydrate or protein provides about 4 calories per gram. Fat offers approximately 9 calories per gram-alcohol falls somewhere in between in terms of caloric content.

Dr. David J Hanson PHD has far more knowledge regarding alcohol and I was intrigued to learn that the National Health Interview Study had documented persons who have one drink per day on average had the lowest BMI's as a group. BMI is an index of weight divided by height and defines being overweight or obese. On his website he went on to explain that if the person drinks 7 drinks in one day as opposed to one drink daily, the once a week drinker would have weight problems statistically. He states that while alcohol has calories the body burns these calories inefficiently.

According to Harrison's Principles of Internal Medicine, 40-50% of men have temporary alcohol-induced problems and 10% of men and between 3% to 5% of women develop persistent alcohol related problems(alcoholism). The alcohol referred to in drinks is chemically known his ethanol. It is a central nervous system depressant that decreases activity of neurons (although some behavioral stimulation is seen at low blood levels). Between 2% and 10% of alcohol ingested is eliminated by the lungs, urine, or sweat but the greatest part is metabolized to acetaldehyde in the liver. The body is able to metabolize approximately one drink per hour. The mechanism of action of ethanol on the nervous system is not fully understood but modest doses can change many neurotransmitters and increase the fluidity of neuronal cell membranes. With regular exposure, our cells adapt and actually undergo structural and biochemical changes that may not return to normal for several weeks or more after stopping.

As just stated, alcohol is a form of calories but offers no nutritional value. Also stated earlier, moderate alcohol consumption appears to have overall health benefits assuming a person doesn't fall into that category of alcoholism. In excess, however, alcohol can affect every single organ system of the body adversely. There are diseases attributed to alcohol in every organ including the skin, bone, gut, blood heart and liver. Excess alcohol intake on a chronic basis can harm any of these tissues and more.

Many people avoid caffeine and many physicians counsel against its use in patients with heart disease. As a doctor I often wonder why! I personally consume coffee on a regular basis and over the years in my career I've seen mostly positive associations as relates to health. Coffee and caffeine in the past was thought to cause cancer of the pancreas but this was proven not to be true in later epidemiological assessments. As stated in Mr. Standridge's book, it is considered the antithesis of alcohol; It provides mental clarity and some would argue helped build America. In my opinion the biggest downfall to being a habitual caffeine consumer is if I don't get my caffeine I begin have withdrawal symptoms within 24-48 hours. Withdrawal symptoms start primarily with a headache and irritability. A recent review in the American Journal of Medicine regarding caffeine and cardiac arrhythmias concluded that the literature is mixed and for the most part there is very little evidence to suggest counseling patients against using caffeine. They did provide the caveat that if individuals personally have associated heart palpitations or cardiac symptoms to caffeine they should listen to their body. A cup of coffee typically provides 115- 275 mg a caffeine. A lethal dose of caffeine is 10,000 mg. One would have to drink an incredible amount of coffee to get to a lethal dose of ingestion. Coffee does raise blood pressure mildly with exercise. Chronic coffee use appears to have little significant relationship to elevated blood pressure.

In conclusion, Plato had it right-moderation is the key. Obviously, if your physician advises against alcohol don't use it.  If you find consuming caffeine makes you feel unwell or your heart skips beats then don't use it. On the other hand if drinking coffee and/or tea leads to improved mental clarity and you find that pleasurable there is no significant medical evidence that drinking it is harmful to you. 

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