Introduction

Internal medicine was, for years, perceived as the “queen of medical sciences.” However, due to the dynamic changes that came with developments in the field of medicine, many subspecialties emerged, hence, the status quo was seriously hindered. In numerous hospitals, due to the adopted method of valuation of carried out procedures, it became necessary to close deficit internal medicine wards or to reduce or combine them with other more highly specialized units. Currently, we observe practitioners striving to achieve highest levels of qualification within narrow subspecialties, while patients, who are aware of the situation, opt to be consulted and treated by these practitioners. In practice, this leads to many difficulties, including long queues to some of the specialists and rise in healthcare costs. The inability to electronically monitor all patient data not only prevents the physician from holistic perception of the patient but, above all, makes it difficult to consider comorbidities while planning therapy, which leads to reduced effectiveness or its lack whatsoever. In this situation, it seems obvious that the efficiency of the healthcare system has to be closely linked to the coordination of specialist care.1-6

The situation described above may lead to many complications and be potentially dangerous. It forced a decline in interest of medicine students, doctors, hospital managers, or decision-makers in internal medicine, both in Poland and other countries. Thus, in the discussion on the condition of the modern internal medicine, there are voices indicating its crisis, underestimation, or dethronement. As a consequence, at least according to some internists, the prestige of internal medicine is also decreasing.2,7,8

Prestige is an assessment of the perception of various manifestations of respect, esteem, reputation, or status in relation to persons, social groups, positions, institutions, and other significant categories that function within the system of social inequalities.9 When we understand it in this manner, prestige, as the autonomous principle of stratification, is a specific good that is always relational, because it is assessed by comparing categories that are placed in higher or lower positions and altogether form a hierarchy. In the essentially subjective assessment of prestige, various criteria are taken into account, such as objective features or values commonly recognized in society, including material status, education, qualifications, power, position, authority, social utility, validity, and even the necessity of the needs being secured, independence, level of responsibility, occupational risk, dedication, or personal qualifications, among others.9

The purpose of the present work was to determine the position of internal medicine in the hierarchy of prestige among current medical subspecialties in Poland and to analyze the sociodemographic factors determining its perception.

Methods

A total of 600 participants over 18 years of age were randomly selected for the study to form a representative sample of the Polish population: sex (100% compliance with calculations based on data from the Local Data Bank [LDB]), age (maximum deviation from the LDB, 2%), number of respondents in a given voivodship (100% compliance with the LDB), place of residence (maximum deviation from the LDB, 1%), level of education (maximum deviation from the LDB, 3%).

The sample was selected randomly (employing the computer-assisted personal interviewing technique), and gaps in the metric data (data collected using the computer-assisted telephone interviewing technique) were filled in by using a number generator to draw telephone numbers from a database of active landline and mobile phone numbers issued by Polish operators. The maximum acceptable standard error of measurement was 4%.

Data come from cross-sectional survey-based research carried out from January to February, 2018, using a mixed-mode survey technique comprising 84% computer-assisted personal interviewing and 16% computer-assisted telephone interviewing. All voivodships were represented, with the most respondents from the Mazowieckie voivodship. The respondents were asked an open question to indicate the medical specialties that, in their opinion, enjoyed the most prestige (“Which medical specialties do you feel most respect for? Please indicate no more than three specialties”).

Statistical analysis

The associations of independent variables such as sex, age, level of education, place of residence, self-assessment of health, and material circumstances were assessed (the characteristics of the study group are presented in Supplementary material, Table S1). Variables were presented as numbers and percentages and compared with the χ2 test. All statistical analyses were performed using the IBM SPSS Statistics software, version 25 package (IBM, Armonk, New York, United States).

Results

Respondents, who were asked to list 3 medical subspecialties they deemed most prestigious, indicated 21 different examples in total. A total of 11.3% of respondents had difficulty making a specific choice and stated that all subspecialties had their utmost respect. Internal medicine ranked ninth, with 8.5% of responses (Table 1). The more popular choices were (starting with the specialties with the highest percentages): surgery, cardiology, pediatrics, anesthesiology, obstetrics and gynecology, neurology, orthopedics, and family medicine. The following specialties were ranked lower than internal medicine: geriatrics, ophthalmology, dermatology, oncology, and psychiatry. Other specialties were only sporadically listed (3 times or less in the entire study group) by the respondents (2.8%): pathomorphology, cardiac surgery, emergency medicine, neurosurgery, neonatology, pulmonology, radiology. A small group of respondents could not answer this question or claimed that they do not have high respect for any of the medical subspecialities (0.7%).

Table 1. The importance of individual medical specialties as indicated by the respondents
Specialtyn (%)a95% CI

Surgery

337 (56.2)

52.2–60.1

Cardiology

252 (42)

38.1–46

Pediatrics

133 (22.2)

19–25.6

Anesthesiology

126 (21)

17.9–24.4

Obstetrics and Gynecology

98 (16.3)

13.5–9.4

Neurology

92 (15.3)

12.6–18.4

Orthopaedics

86 (14.3)

11.7–17.3

Family Medicine

55 (9.2)

7.1–11.7

Internal Medicine

51 (8.5)

6.5–10.9

Geriatrics

47 (7.8)

5.9–10.2

Ophthalmology

43 (7.2)

5.3–9.4

Dermatology

39 (6.5)

4.7–8.7

Oncology

9 (1.5)

0.7–2.7

Psychiatry

4 (0.7)

0.2–1.6

a Percentages do not add up to 100 because respondents could indicate more than 1 specialization

The analyzed sociodemographic variables (sex age, education, place of residence, self-assessment of health condition, and assessment of material status) did not differentiate the perception of internal medicine among the respondents (Supplementary material, Table S1).

Discussion

Internal medicine was placed in the middle of the ranking, on the ninth place among 21 of the most prestigious specialties listed by the respondents; however, the small percentage of responses demonstrates its relatively low importance in the opinion of Poles. The data are partly consistent with the results obtained by other authors (additional data are described in Supplementary material, Table S2). A review of studies on the prestige of medical subspecialties, including internal medicine, demonstrated that it usually occupies high or middle positions in the rankings, while the surgical subspecialties usually are ranked higher. The respondents were most often people closely related to medicine due to their education or profession. Furthermore, while various research procedures were applied, almost always a set of medical specialties was given to the respondents. Therefore, they did not include all available categories.

A comparison of the results of our own research and other authors does not allow to unequivocally state that the prestige of internal medicine is stable over time and in various countries (Supplementary material, Table S2). The Polish general population hold different opinions than the previously studied groups of medical students, doctors, employees of other medical professions. Of note, some internal medicine subspecialties, both in our own research and elsewhere, are ranked above generalized internal medicine (Supplementary material, Table S2). This in fact may indicate the specialty’s degradation, which has come about as the result of its division into highly specialized subspecialties.

The above list prompts the search for factors that may have influenced the assessment of the prestige of internal medicine. Various authors suggest that the current situation of internal medicine should be interpreted in relation to: 1) the healthcare system and its environment, 2) the organizational structure of hospitals, and 3) features typical of the respective medical specialty.10,11

Particularly noteworthy, however, is lack of influence of sociodemographic factors on the perception of the prestige of internal medicine. This may indicate the universality and “democratic” nature of this specialty in the sense that it is required by various patients, regardless of their level of education, sex, or social status, etc. On this basis, the role and significance of internal medicine can be reestablished, especially when facing an increasing need for coordinated care.1,3,4,7,12

Conclusions

The position of internal medicine in the hierarchy of prestige of medical subspecialties is quite low and some internal medicine subspecialties are ranked above it. Our data confirm, to some extent, the opinions about the decrease in the prestige of the internal medicine.

The prestige of internal medicine did not depend on the sociodemographic characteristics of the respondents. This may indicate that in the respondents’ opinion, this specialty is universal, namely, it is needed by various patients, regardless of their education level, sex, or social status, etc. This can be the basis for the restoration of internal medicine’s role and significance, especially in times of intense changes in the field of teaching and medical practice, but also the growing demand for the formation of coordinated care.