The hospital Internal Medicine specialist today: a literature review and strength, weaknesses, opportunity, threats (SWOT) analysis to develop a working proposal

摘要

The aim of the paper is to identify the role of the hospital Internal Medicine specialist in the Internal Medicine Unit (IMU) through a clinical and statistical analysis of the patients referred to them by identifying the activities that differentiate them from patients in General Medicine and Emergency Departments, i.e. diagnosis and treatment of complex patient with varying degrees of instability, identifying priorities in the acute problems of co-morbidities. The modified early warning score (MEWS), an internationally validated marker, was chosen to assess and stratify the clinical instability of patients referred to the IMU. A literature review was carried out, and a cut-off score of 3 was chosen to define the critical patients referred to the IMU; a MEWS value of 4 defines the need for transfer to the Intensive Care Unit (ICU) or Intensive Cardiac Care Unit (CCU), considered the primary end point in most of the studies examined. To better characterize the internist’s role today, a strength, weaknesses, opportunity, threats (SWOT) analysis was performed and examined, and commented upon. A total of 101 articles were reviewed and 5 were selected. The case histories relating to the IMU appear to be made up of complex patients with conditions that are, in most cases, acute and unstable. From 10% to 17% of patients present a MEWS of 3 or more that defines a condition of severe clinical instability requiring continuous observation and non-invasive multi-parametric monitoring. From 5% to 7% of cases present a MEWS of 4 or more and therefore require transfer to the ICU/CCU or risk rapid death. Approximately 40% of patients present MEWS of 1-2 and still have disease flare-up, but with a lesser degree of instability; however, these patients could experience a potentially negative disease development if not promptly and properly treated. Approximately 40% of patients have MEWS of 0 and represent the group of fragile patients that cannot be studied, diagnosed or stabilized on an outpatient basis. The critical analysis of the literature review and the SWOT analysis suggest that the two specific hospital internist’s tasks are: i) to stabilize acute, severe and complex patients with multiple pathologies; and ii) to develop etiologically difficult diagnoses in these and in fragile patients who need to be admitted to the hospital because the alternative diagnostic routes, for various reasons, cannot be used.