Reflections on internal medicine in Poland on the occasion of the 100th anniversary of Polish Archives of Internal Medicine

Introduction

The centenary of Polish Archives of Internal Medicine (Pol Arch Intern Med) is a good opportunity to express our gratitude to all the people whose work over the last 100 years has contributed to the standing and authority of this flagship journal of the Polish Society of Internal Medicine (PSIM). Words of thanks are due to all the successive editors-in-chief, chairs, and members of the Scientific and Editorial Boards, as well as the authors and reviewers of papers. However, special thanks and congratulations are due to Professor Anetta Undas, who has been the editor-in-chief of the journal since 2008. Under her leadership, Pol Arch Intern Med has become the highest-ranked Polish journal in the field of clinical medicine and has earned a very high position in all major international scientific rankings.

What is internal medicine?

Irrespective of our gratitude for the illustrious history and satisfaction with the achievements and current standing of Pol Arch Intern Med, the 100th anniversary of its foundation is also an opportunity to reflect on the current state and prospects of Polish internal medicine. The discussion on the place and role of internal medicine and the challenges facing this medical specialty is not peculiar to Poland. It has been going on for several decades in almost all countries with different health care systems.¹ However, despite many dissimilarities related to the adopted solutions, levels of economic development, state systems, and cultural differences, the challenges facing internal medicine in all these countries largely overlap. The word that comes up most often in this discussion is “uncertainty.” It first emerges when attempting to define the specialty of internal medicine and to answer the question of who is an internist, that is, a specialist in general internal medicine. It is easier to define what distinguishes an internist from an externally intervening surgeon, but the difference becomes more difficult to pinpoint when it comes to a subspecialist and a general practitioner. Professor Eugeniusz Kucharz wrote about such an understanding of internal medicine in his letter as the PSIM President on the occasion of the 100th anniversary of the Society’s foundation.²

Who is an internist?

Historically and etymologically, the term “internal diseases” refers to diseases affecting the inside of a human, excluding injuries. The rapid development of medical knowledge and associated technological advances have resulted in the emergence of many subspecialties, as well as of specialties that are currently not even included in internal medicine in the broadest sense, such as neurology, dermatology, oncology, and infectious diseases.

According to one of the several currently proposed definitions, internal medicine is a field wherein a physician applies scientific knowledge and clinical experience to the diagnosis and treatment of a broad spectrum of diseases in adults and provides counselling to prevent these diseases. It is difficult to define what this spectrum is, as its scope usually depends on current needs and circumstances. Indeed, an important task of the internist is often to substitute for various specialists who are lacking at a given place and time, since internal medicine is the only medical specialty that does not target specific systems and organs of the body (such as cardiology or gastroenterology), specific disease mechanisms (such as oncology or allergology), or even specific groups of patients (such as geriatrics).²

Internal medicine specialists must be able to differentiate between the causes of the patient’s complaints and physical symptoms, distinguish health from disease, diagnose and differentiate between 2 or more conditions, and treat patients. They should also be able to distinguish symptoms of a disease from abnormalities that do not cause adverse outcomes in order to avoid harmful overdiagnosis (overdetection) and treating risk factors as a disease (overdefinition). The true mastery of a physician, including the internist, lies, among other things, in the appropriate evaluation of the patient’s complaints and physical symptoms, and in alertness to avoid treating abnormalities that are not clinically significant or resolve spontaneously.³

In addition to the skills mentioned above, it is important that internists have an understanding of the factors that adversely affect the body in order to provide competent counselling and intervene skillfully to improve general health and prevent disease. They should also be able to provide comprehensive palliative care for adult patients of all ages, and treat mental disorders, such as anxiety or depression.

Polish practice of internal medicine

Due to the specific nature of their work, the internist in Poland is often synonymized with the general practitioner. Also, due to the very low number of geriatricians, it is common for the internist to act as a substitute for this specialist. It should also be noted that the majority of patients admitted to internal medicine departments in our country have already reached geriatric age.

Specialization in internal medicine is based on working in hospital wards, and this is what distinguishes it most from the practice of the general practitioner. The internal medicine department has to “cope” with a patient referred by the general practitioner or by a specialist who is not able to establish a diagnosis or treat the patient effectively on an outpatient basis. Some patients are transferred from specialist departments that do not have the means or technology to help the individual concerned.

Given the Polish reality, it is highly foreseeable which of the patients presenting to the admission unit or hospital emergency department will be admitted to the internal medicine department. It is usually a patient who is not eligible to be treated as a day-case or a patient with at least 3 diseases falling within at least 2 specialties. Whatever the circumstances, it is clear the patient needs medical care, but it is not obvious where to admit them. Internal medicine departments in Poland frequently also function as detoxification units, hospices, or even as social care homes and shelters for the homeless. All the aforementioned cases are a reason for the chronic underfunding of internal medicine departments, which is noted in many countries.⁴ In Poland, however, inadequate funding is a persistent and widespread problem, in extreme cases resulting in the shut-down of these departments. An additional factor aggravating the unfavorable financial situation of internal medicine departments is insufficient supply of modern equipment, mainly channelled to wards with narrow specializations. This strongly indicates that the most important decision-making bodies in our country do not regard internal medicine departments as, even potentially, high-quality care centers that could become referral centers. This is to the detriment not only of these departments, but of medicine as a whole and, above all, of patients. Division of patients into “better,” that is, those requiring a spectacular procedure, and “worse,” that is, those needing tedious diagnostic testing or even “only” care and observation, is profoundly unfair to both the patients and the doctors who provide them with medical care.

Meanwhile, it is the diagnosis and treatment of patients hospitalized in internal medicine departments that can pose a very serious challenge to the clinician. This is because, most frequently, these patients present with multimorbidity and iatrogenic complications, and report a wide variety of uncharacteristic symptoms, often difficult to treat in compliance with the guidelines and recommendations of the relevant scientific societies for specific diseases. The management of such patients requires not only the skill of appropriate pathophysiological reasoning based on extensive knowledge and acquired experience, but many times also the civil courage of the physician.

The causes of hospitalization are usually related to chronic, lifestyle-related diseases, for which the most important element of treatment is the elimination of the unfavorable behavior. Explaining this to the patient requires remarkable communication skills and patience. Unfortunately, the process often resembles the work of Sisyphus, and leaves the doctor facing accusations of incompetence as well as lack of empathy and goodwill. In these scenarios, consistency and the aforementioned civil courage of the doctor are particularly needed. In my opinion, convincing the society, which is medicalized and indoctrinated by misleading advertisements, of the relevance of personal responsibility for its own (and others’) health is the most important task and challenge of modern medicine. In fulfilling this responsibility, an important role rests with the internist.

The role of the internist in the integration of different medical specialties

Dynamic development of medicine in the 20th and 21st centuries has only been possible due to its split into narrow specialties. It has become impossible for physicians to capture the whole body of medical knowledge, and hence new subject fields continue to emerge. Any progress demands a tedious and repetitive research; therefore, in clinical practice, the increasingly complicated and costly technologies can only be mastered by small groups of highly-qualified specialists. However, diagnosis and treatment are not about matching a patient with the latest and most sophisticated technologies. They are about finding an optimal patient-oriented solution, taking into account their clinical condition, comorbidities, prognosis, drug-related side effects and drug interactions in polypharmacotherapy, and, as the experience of the pandemic has taught us, the capacity of the health care system. No recommendations are available on how to combine all these elements.

It often seems to us that large clinical trials will create a “model patient”; however, such a patient will never really be seen. Each and every human being in any outpatient clinic or hospital ward is a unique individual, not only mentally but also physically, a model and a separate entity for themselves, even if they carry some genetic or epigenetic variation. When health problems impair the quality of life or threaten to shorten it, “the patient” becomes the way of medicine,² and internal medicine is a type of this way, and it cannot be ignored if the intended goal is to maximize health.⁵ This is because it has been shown that a continuous increase in the number of narrow specialties, while sometimes beneficial for individual patients, does not improve the global health of the society. Thus, the path in which doctors, under pressure from the overwhelming vastness of medical knowledge and the constant development of science, seek to narrow their practice to the area in which they feel competent, has proved ineffective, or at least insufficient. Achieving mastery level in treatment procedures is not enough, as it is not the diseased organ, or even the whole organ system, but the human being as a whole that needs help. This human being is affected by various adverse factors, including trauma or microorganisms, as well as factors related to negative environmental changes. For this reason, personal contact between the doctor and the patient is no longer sufficient. More comprehensive actions are needed, involving education of the society and emphasis on implementing the results of these educational efforts.

The issue is further complicated by the increasing incidence of psychosomatic diseases, the diagnosis and treatment of which require not only extensive knowledge of the physicians but also their ability to effectively communicate with the people who entrust them with their health. Gaining the patient’s trust is necessary to bring out deeply buried problems, while correct qualification and effective resolution of these problems are among the most important but also the most difficult medical competences. A doctor must bear in mind that the patient does not really expect better biochemical test results or improved health indicators, but their sense of health and fitness to be restored.

Meeting all these expectations is beyond the capacity of even the most competent doctor, or a single narrow specialty. What is needed is a collaboration of different specialists, both medical and surgical, each relying on the consultation with the other. The future of medicine does not lie in bitter rivalry but in cooperation, with doctors recognizing the need to “share the glory.” The key role rests with a physician with good general internal medicine skills and the right motivation to act. Better collaboration with representatives of narrow (sub)specialties is facilitated by the internist’s in-depth knowledge of at least 1 of these specialties; formal certification in this area is of minor importance.

Achieving the abovementioned competencies is impossible without having good knowledge of the scientific research paradigm and personal engagement in medical research. Such in-depth knowledge of the fundamentals of clinical practice enhanced by the ability to draw sound pathophysiological conclusions enables doctors to solve the most difficult and complex diagnostic and therapeutic problems.

The role of a master in the teaching and practice of medicine

The above considerations prompt the question: how can the level of medical art described above be achieved? Although each doctor has to find their own way, the process is greatly facilitated by relying on available personal role models, who are trusted to possess all the necessary professional and ethical competences. Such an exemplary teacher of the art of medicine is referred to as a master. A master is characterized not only by the basic, efficiency-oriented qualities of action, such as rationality, regularity, efficiency, effectiveness, and productivity, but also meets certain axiological expectations, including responsibility, fairness, as well as being highly principled and truthful. The entire picture is completed by nobility, care, and altruism.

Polish internal medicine can proudly boast many such masters, including academic teachers, specialization supervisors, heads of hospital wards, or “simply” colleagues.

However, there are masters whose scope of influence is much broader than a single department, hospital, or university. They meet all the criteria of a dedicated doctor and teacher; their example radiates throughout the country and far beyond its borders. They are outstanding scholars, in a real sense expanding the horizons of their field of knowledge. At the same time, they do not lose the qualities of an empathetic doctor and a caring guide for their students. They become unquestionable authorities in every sense of the word, earning widespread recognition and trust of the community through their professionalism, ethical stance, and accuracy of judgment. Their authority does not derive from any title they have been conferred or any function they have ever held, but from their personal charisma and the recognition of their professional achievements and life testimony.

The reflections presented here would be incomplete without giving examples of such masters of Polish internal medicine. The choice of specific names is always a matter of discretion and may be subject to discussion, so it is appropriate to provide some explanation. I mentioned 4 individuals, most of whose life and work fell during the difficult period when Poland was separated from the rest of Europe by a more or less tight Iron Curtain, and the freedom of scientific activity and international collaboration were, for various reasons (including economic), significantly restricted. Despite these unfavorable circumstances, there were people among us who upheld the supremacy of truth and the right way of seeking it. And so they did against the inclinations, prejudices, superstitions, and extrinsic interests which tempt all of us to accept as true whatever we consider convenient.⁶ Through their efforts, Polish medicine (including internal medicine) was intellectually prepared for the changes initiated throughout Eastern Europe in the late 20th century. And furthermore, the example of the lives and work of the featured masters of Polish internal medicine remains relevant and befits every difficult time and circumstances we are confronted with.

A secondary but important criterion for choosing the presented masters was the opportunity to have personal contact with them.

Kornel Gibiński

One of undeniable authorities for Polish internists, whose life and work were an outstanding example and who accurately predicted the directions of development in medicine in the 20th and 21st centuries, was Professor Kornel Gibiński.

Born in 1915, when Poland was not yet on the map of Europe, he graduated as a doctor at the outbreak of World War II in 1939. His first years of professional work fell during the harsh period of Nazi occupation. For his activities in the underground resistance movement, he was imprisoned in the Gross-Rosen concentration camp and sent to work in quarries, and later as a doctor of forced laborers. As he later recounted, the experience of that time led him to conclude that everything could be lacking in medicine, but not the mind and heart of a doctor. He remained faithful to this principle throughout his life.

Since 1953, the year he was awarded the title of professor, he headed the Department of Internal Medicine, and from 1975 until 1985, the year he retired, he headed the Department of Gastroenterology at the Medical University of Silesia in Katowice, Poland.

Continuing the work of his teachers, Professors Aleksander Oszacki, Jerzy Klaubersz, and Edward Szczeklik, he was one of the most outstanding contributors to academic internal medicine in Poland. At successive stages of his career, Professor Gibiński was involved in several subspecialties of internal medicine, making significant contributions to the development of hematology, cardiology, gastrology, nephrology, water and electrolyte metabolism, clinical enzymology, clinical pharmacology, as well as environmental health and epidemiology.

He published many papers in leading Polish journals, mainly in Pol Arch Intern Med, as well as in major international journals, including Circulation,⁷ J Atheroscler Res, Arch Immun Ther, Enzyme, Thromb Diath Haemorrh, Metabolism, Gut, Hepato-gastroenterology, Chronobiologia, Scand J Gastroenterol, Gastroenterology, and Analecta Husserliana.

Professor Gibiński was the author and editor of many Polish and foreign textbooks, mainly on gastroenterology, including the first Polish textbook in the field, Outline of Clinical Gastroscopy, published in 1959. He supervised PhD theses of 43 doctors of medical sciences, of whom more than 20 became professors.

It is impossible to list all the honors and distinctions he was awarded with. Among them are honorary memberships in many Polish and foreign scientific societies, honorary doctorates from 4 universities, including the Jagiellonian University, membership of the Polish Academy of Sciences and the Polish Academy of Arts and Sciences, as well as the functions of the vice-president of the European Society of Endoscopy and the World Gastroenterology Organization.

Crucial aspects of Professor Gibiński’s organizational and publication activities were the ethics and philosophy of medicine. His contribution to this field remains surprisingly relevant to the present day and contains guidance to help solve new ethical problems arising in medical science and practice, and even ready answers to many difficult questions. He is also the inspiration for many of the points raised in this paper. In one of his last articles,⁸ he included the following message: “…ethics cannot be imposed, nor can it be taught from a textbook, but it needs to be constantly reminded of, and confronted with bewildering situations, at the origin of which there may not have been evil intentions threatening the order of the world that had once raised man, who now takes an active part in shaping it.” Professor Gibiński also urged that “while watching the development of natural sciences and social changes, one should not shut their conscience, which is an essential element of a human.”⁸ Confronting these reflections with many recent and current events in Poland and around the world, as well as with the problems of medicine and the health care system (these are not synonyms), it would be hard not to recognize their timeless relevance.

Franciszek Kokot

One of Professor Gibiński’s students was Franciszek Kokot (Figure 1), born in 1929 in a small town in Opole Silesia, which remained within the borders of the German Reich until 1945. He completed high school and medical studies in Polish Silesia, and in 1953 began working in the Department of Internal Medicine headed by Professor Gibiński. Medicine was the catalyst for their encounter and a long-lasting friendship that followed. Coming from a very poor family living on the outskirts of Germany and carrying a burden of wartime youth, Franciszek Kokot became a true self-made man of Polish medicine. However, he always emphasized how much he owed to Professor Gibiński—his master and teacher. He was able to use the burden of the experience of a borderland man to promote and strengthen the position of Polish medicine, and to be active in the process of rapprochement between Poland and Germany, countries with a common difficult past. He had become one of the pioneers of the European integration many years before Poland joined the European Union.

Scientific and professional interests of Professor Kokot included biochemistry, pathophysiology, pharmacology, and nephrology, with a focus on clinical enzymology, pathophysiology of the endocrine system in patients with chronic kidney disease and acute kidney injury, disorders of the renin-angiotensin-aldosterone system, parathyroid diseases, and the effects of water immersion on renal and endocrine function. He was an author and co-author of more than a thousand publications, including dozens of textbooks of international importance and distribution. His papers were published in Kidney Int, Clin Nephrol, Contrib Nephrol, Am J Nephrol, Nephron, Nephrol Dial Transplant, Miner Electrocyte Metab, Eur J Clin Invest, Hypertension, Hypertens Res, Kidney Blood Press Res, Metabolism, J Cardiovasc Pharmacol, and J Hypertens.

His papers in Polish were mostly published in Pol Arch Intern Med. He was the chairman of the Scientific Council of this journal for many years. His extraordinary translational activities were inestimable. He made dozens of excellent English- and German-language textbooks available to Polish physicians. It is no overstatement to claim that it would be difficult to find a doctor in Poland, and certainly a specialist in internal medicine or nephrology, who does not owe Professor Kokot some part of their education. The extent of his didactic work is evidenced, among other things, by the fact that he supervised PhD theses of 77 doctors of medicine, 28 of whom became professors. His entire professional and scientific career was associated with the Medical University of Silesia, of which he was the rector from 1982 to 1984.

Professor Kokot was a full member of the Polish Academy of Sciences and an active member of the Polish Academy of Arts and Sciences; he was awarded honorary doctorates by 11 universities. He was an honorary member of several Polish and more than a dozen foreign scientific societies. In 2012, during the 49th European Renal Association—European Dialysis and Transplant Association (ERA-EDTA) Congress in Paris, he was ranked among the elite group of the most outstanding pioneers of European nephrology. It is, in fact, impossible to list all the Polish and foreign prestigious awards he was honored with.

In Poland, he was an undisputed medical authority recognized not only by internists and nephrologists. Every meeting with him was an unforgettable lesson. The most impressive were his ability to synthesize complex scientific and clinical issues and his accuracy in assessing the importance of the problems of modern medicine. He commented that scientific work was a kind of addiction for him, and that pursuing the truth brought him joy and motivation for life.

More details on Professor Kokot’s scientific and teaching activities and his importance to internal medicine and nephrology both in Poland and worldwide are presented in a memorial article published in Pol Arch Intern Med.⁹

Andrzej Szczeklik

Professor Andrzej Szczeklik (Figure 2) takes a very unique position in the history of Polish internal medicine. The son of an outstanding internist and cardiologist, Professor Edward Szczeklik, he graduated not only from the Faculty of Medicine but also from the school of music. He was a remarkable example of a versatile erudite who, while first and foremost a great physician, was also a world-renowned scientist, philosopher and medical ethicist, essayist, and pianist.

Born in 1938, he received his medical degree in 1961. After graduation, he obtained several fellowships and was a visiting professor in the United States, Great Britain, Sweden, and Switzerland. From 1972 to 2008, he headed the Department of Internal Medicine in Kraków. He was the author or co-author of more than 600 scientific papers on cardiology, pulmonology, and immunology. His major achievements include a theory of the development of aspirin-induced asthma, studies on thrombin formation, description of the effects of prostacyclin in man, and the discovery of leukotriene C polymorphism.

It is impossible to list all prestigious awards with which he was honored. Among those he valued most were memberships in the Polish Academy of Sciences, the Polish Academy of Arts and Sciences, and the Pontifical Academy of Sciences at the Vatican, honorary memberships in the Royal College of Physicians London and the American College of Physicians, honorary doctorates from 5 universities, first prize from The Lancet for research on bronchial asthma, and the grand prize from the Foundation for Polish Science (known as the Polish Nobel Prize).

Professor Andrzej Szczeklik was first and foremost a doctor, about whom the most prominent Polish intellectuals and artists wrote, among other things, that he was gifted with an “absolute ear” in music and medicine. His example motivated not only his closest colleagues but also those who did not know him personally. His 3 books—essays on the links between medicine, history, and art—demonstrated extraordinary erudition and in-depth knowledge of the issues raised. All became bestsellers in Poland and were translated and published abroad.

Andrzej Szczeklik’s uniqueness was also evident during the historical changes in Poland in the 1980s. Disregarding personal harassment and risking a severe hindrance to his scientific development, he was actively involved in the Solidarity movement, both in the first overt period and later in the underground, until the collapse of real socialism in 1989.

Emphasis should also be placed on his key contribution to the success of Pol Arch Intern Med as the chairman of the Scientific Council, but also, and perhaps most importantly, invaluable support to the editor-in-chief in the decision-making process that, as we all know, can be difficult. Professor Anetta Undas mentioned this in a special issue of the journal in 2012¹⁰ and on the 10th anniversary of Professor Szczeklik’s death.¹¹ These articles portray a doctor-internist, an artist, and a philosopher, who belonged to the elite making the world a better and brighter place.

Włodzimierz Januszewicz

Born in 1927 in the territory of present-day Lithuania, Professor Włodzimierz Januszewicz (Figure 3) through the tragic years of World War II in the capital of occupied Poland, where he fought in the Warsaw Uprising at the age of 17. After receiving his medical degree in 1951, he began working at the Department of Internal Medicine headed by the eminent Polish internist, Professor Dymitr Aleksandrow. After his scientific internships at the Karolinska Institute and the Columbia Presbyterian Medical Center, the etiology and pathophysiology of the world’s most common lifestyle disease, that is, hypertension, became his main area of scientific activity. He was one of the world’s co-founders and undisputed leader of Polish hypertensiology. As he himself emphasized, the development of the subspecialty was not possible without a solid foundation in internal medicine. Therefore, regardless of the scientific interests that made him world-renowned, he has remained an outstanding internist. He created a team of excellent affiliates, with whom he published more than 350 papers, including in N Engl J Med. He was the supervisor of 40 doctorates, and 12 of his graduates became professors. He was honored for his work with many scientific and state awards. He was awarded honorary doctorates by the Medical University of Silesia and the Poznan University of Medical Sciences, received the Alberto Zanchetti Award of the European Society of Hypertension, became the Honorary President of the Polish Society of Hypertension, an honorary member of the Polish Society of Cardiology, Polish Society for Atherosclerosis Research, and PSIM. He is also a full member of the Polish Academy of Sciences and an active member of the Polish Academy of Arts and Sciences.

Conclusions

The different life paths of these 4 honorary members of PSIM mirror the complex history of Poland in the second half of the 20th century and at the turn of the 21st century. Although the scientific interests in which they achieved worldwide recognition involved different research areas, they all are and will continue to be masters of Polish internal medicine for their colleagues and doctors in our country. By personal example, they taught both reasoning and arduous work. While striving to acquire and expand their knowledge throughout their careers, they remained committed to their patients. They were all passionate about work, and, last but not least, tied together by long-standing friendships.

With their publishing and organizational activities, they have built the foundation for the success of Pol Arch Intern Med. Their students strive to continue the various themes and directions of their activities and remain faithful to their message.