[Organizational structure of internal medicine in Chile]

Internal Medicine, as a comprehensive discipline, has become increasingly dismembered during the last decades due to several reasons, some of which are the growing complexities of its practice, its obstinate confinement to hospital-based practice, its generation of and subsequent disfunction from general internal medicine and the medical subspecialities. In Chile internal medicine is currently organized in three levels of patient care, each of anarchical and distortioned proportions. These levels do not constitute a fluent network of progressive patient care but rather an heterogeneous combination of ironclad compartments in search of their own autonomy. A few of the many problems and challenges that internal medicine faces in Chile are: (a) in primary care medicine, problem-solving abilities must be improved and programmed care must be privileged over free choice. Specialist in general medicine must be assigned to primary care and multiprofessional teams must be strengthened; (b) Secondary care is underdeveloped due to the waning prestige of internal medicine and waxing attractiveness of its subspecialities. Programmed formation of specialist in internal medicine has been so far rigorous and demanding, but excessive in number in relation to available post. This leads trained internist to practice as subspecialist, without having the adequate conditions for such a practice. To avoid this situation, the scope of internal medicine emergency wards, integral medicine clinics, and medical student teaching should be handed over to it; (c) Tertiary care is a task of subspecialist. It is not known how many subspecialist are required, or how many physicians are currently practicing as a subspecialist. Most of the currently practicing subspecialist are self-qualified or have received quick training through short rotations by not always well-qualified centers. Many are only former internal medicine residents. In this setting, it is not possible to devise a prospective plan of subespecialty training. To make internal medicine in Chile efficient and timely, its is necessary to restore and restructure a rational patient care network that will do away with the current red tape and waiting list as well as to allow the insertion of well-trained specialist in the corresponding levels of patient care.