The role of the internist is more demanding than ever with increasingly shorter visits, higher expectations, and systems that often hinder more than help. Internists stand at the center, navigating complexity with compassion.

Dr. Douglas Paauw, professor of medicine at the University of Washington and a practicing internist for more than three decades, reflects on how the field has changed—from telehealth’s rise to the digital communication overload—and what it takes to thrive today.

Discover the trends reshaping internal medicine and how to keep care both effective and human.

The Split Between Inpatient and Outpatient Care

Internists once followed their patients through every stage of care: clinic visits, hospital stays, and everything in between. That’s no longer the case. Over the last two decades, internal medicine has shifted to a model where hospitalists handle inpatient care, while primary internists manage the outpatient side.

The result is a clearer division of labor, but also a loss of continuity. In today’s system, physicians “who are so specialized in the care of the sickest patients and give absolutely top-level care there have to also figure out a way for those patients who just meet them to trust them,” says Dr. Paauw. “And then, more importantly, when they're ready to leave the hospital, have a good hand-off to the doctors who are going to be taking care of them in the outpatient setting.”-+

This structure has clinical advantages. Hospitalists are trained to manage the sickest patients and provide high-level acute care. But the disconnect between hospital and home care can complicate recovery. Internists must rely on strong communication, thorough documentation, and effective care coordination to keep patients from falling through the cracks. 

The Rise (and Limits) of Telehealth

Telehealth has changed how internists deliver care. Virtual visits offer newfound access for many patients, especially those with mobility challenges or long travel times. And increasingly, they’re taking advantage of telehealth options.  

These virtual visits “are really a wonderful thing for patients to be able to access their physician or healthcare professional in a quick way when they need it,” says Dr. Paauw. “And for some patients, it's very difficult to get into the clinic.”

But telehealth also comes with trade-offs that aren’t always visible on the surface. “You get a limited data set. You can't examine the patient,” says Dr. Paauw. “There's a feel that you get when you're in a room with a patient—sick, not sick—that is a little harder on a telehealth visit.”

Telehealth is here to stay, but Dr. Paauw emphasizes the importance of balancing convenience and clinical judgment. For internists, that means knowing when a virtual visit is sufficient and when to bring a patient in.

Shorter Visits, Bigger Expectations

Time is one of the scarcest resources in medicine. Internists today are expected to provide high-quality care, address complex issues, and maintain strong patient relationships—all in 15 minutes or less.

“If you are working for a company, they have productivity goals that say you're going to be able to generate your salary if you see this many patients in a day,” says Dr. Paauw. “Those numbers often are pretty unreasonable. To give great quality care, you need time with your patients, because the best way we can care for patients is to listen.”

He sees the consequences firsthand. Some of Dr. Paauw’s colleagues “have 10-minute time slots, and that just gets enough time for a patient to get in the room, get their vital signs checked, say hi, and then get ready to leave.”

These short visits complicate efforts to catch early warning signs, address multiple concerns, or build the trust that drives adherence. Patients may leave without fully understanding their condition—or worse, without being truly heard.

The 24/7 Patient Portal

The advent of patient portals has given patients a direct line to physicians—but also created an invisible workload that’s often unrecognized and uncompensated.

“The single biggest change in expectations from patients as we care for them in the outpatient world has been … portals where patients can send messages to their physicians 24 hours [a day],” says Dr. Paauw. “This is a huge positive in the sense that patients can reach out to their physicians. It's also, again, a double-edged sword.”

What once happened in-office now floods inboxes. Physicians, already stretched thin, often spend hours after work answering patient messages—a pace Dr. Paauw calls unsustainable.

Though driven by a desire to help, this after-hours model leads to fragmented care and burnout. On the flip side, patients can face delays or impersonal replies, leaving both parties feeling unheard and frustrated. 

Internists as De Facto Geriatricians

With too few geriatricians to meet demand, internists increasingly manage care for aging patients with complex needs.

“There are very few of them in the United States, and estimates [say] we have about 5% to meet the needs of our older patients,” Dr. Paauw explains. “So internists have taken on the role of becoming geriatricians.”

The care of older adults requires a shift in mindset. “Guidelines that are really good for a 50-, 60-, even an early 70-year-old may be crazy for a person in their 90s,” he says. “As we get experience taking care of our older patients, we get an understanding and an appreciation for sometimes, less is more.”

Internists are stepping into this gap as primary care providers who are also specialists in nuance—balancing evidence-based medicine with the realities of aging, polypharmacy, and quality of life.

The Shift to Team-Based Care

Modern internal medicine is increasingly collaborative. Pharmacists and behavioral health specialists are no longer peripheral—they’re becoming essential to comprehensive care.

“Our pharmacists look at this, and they double-check it. They're a wonderful safety net for us,” says Dr. Paauw. “I do lean on my pharmacist to cross-check everything I do.”

Collaboration with mental health providers is just as critical. “Many of our patients have mental health concerns,” he says. “The best system we can have is full integration with a behavioral health specialist.”

Unfortunately, most clinics don’t have that support. “Access to behavioral health specialists can be limited in many, many areas, especially rural areas,” Dr. Paauw adds.

Prepare for the Future of Medicine

From virtual care to growing complexity, internal medicine is evolving fast. As Dr. Paauw notes, internists are meeting the moment—but they need systems, tools and support that matches today’s demands.

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