IMAGINE - Internal Medicine Assessment of Gender differences in Europe (now closed)

IMAGINE WG aims at exploring the gender-related differences in clinical presentation, diagnosis and treatment of clinical conditions in Internal Medicine. 

Despite increasing evidence that an individual’s sex is one the most important modulators of disease risk and response to treatment, consideration of the patient’s sex in clinical decision making (including the choice of diagnostic tests, medications, and other treatments) is often lacking. This is surprising given the increasing interest in precision medicine, which should begin with attention to sex differences in medicine. Sex and Gender Oriented evidence-based medicine could lead to significant improvement of medical knowledge and to a considerable progress of clinical practice.

Despite the aforementioned magnitude, there is still a lack of data on different effect of drugs according to sex. Moreover, there is a reduced awareness of biological, physiological and epidemiological differences between the biology behind the medicine in men and women.

EFIM IMAGINE Working Group published their paper  "IMAGINE the future - a voice of young internists" in JAMA under the title "Sex, Gender, and Precision Medicine". Article can be accessed via JAMA website.

Primary contacts EFIM :
Chair: Ewa Biscup, Swiss Society of General Internal Medicine, Switzerland  and Valeria Raparelli - Italian Society of Internal Medicine, SIMI - Italy

Representatives to the IMAGINE WG from EFIM Members' national societies:

  • Alexandra Kautzky-Willer - Austria
  • Risto Kaaja - Finland
  • Sophie Teege - Germany
  • Eleni Karlafti - Greece
  • Lotan Dor - Israel
  • Maria Perticone -  SIMI Italy
  • Stefania Basili - SIMI Italy
  • Cecilia Politi - FADOI Italy
  • Elena Barbagelata - FADOI Italy
  • Immacolata Ambrosino - FADOI Italy
  • Jacqueline de Graaf - The Netherlands
  • Andreia Villas Boas, Portugal
  • Asunción Gonzalvez Gasch - Spain
  • Ana Maestre - Spain
  • Karin Schenck-Gustafsson - Sweden

Rare Diseases (now closed)

Chairman : Lorenzo Dagna
To promote the awareness on Rare Diseases in Europe and to imagine common European strategies for patients with rare diseases.

Rare diseases are one of the most characteristic topics of Internal Medicine, since they are multi-systemic and complex. Rare diseases are characterized by a broad diversity of disorders and symptoms that vary not only from disease to disease, but also from patient to patient suffering from the same disease. Also, patient mobility across European borders is a reality for people living with rare diseases.

Specific primary aims of the Rare Diseases Working Group of EFIM are: 
• to gather data on rare disease in European Internal Medicine departments;
• to gain and share scientific knowledge about all rare diseases;
• to increase the awareness on rare diseases among Internists across Europe;
• to imagine and create specific curricular tracks on rare diseases for medical students and Internal Medicine residents;
• to implement the development of European research projects on molecular and pathophysiologic aspects of rare disease;
• to possibly coordinate future European multicentric clinical trials on rare diseases.

General and future aims of the Working group will be: 
• to implement the comprehensive approach which is peculiar to Internal Medicine to rare diseases;
• to support the development of appropriate EU public health policies for rare diseases;
• to increase international cooperation in scientific research among EFIM members;
• to coordinate studies aimed at developing new diagnostic and therapeutic procedures;
• to support campaign aimed at raising public awareness of these disease in the EFIM Countries;
• to provide comprehensive quality information to the rare disease community.



Competencies and European Board (EBIM)

President: Werner Bauer

In 2003 there was formal agreement to set up a European Board of Internal medicine by EFIM and UEMS as laid down in the EU regulations. This has the primary objective of developing a European Diploma in Internal Medicine, as has been successfully achieved by other sub-specialties such as cardiology and urology. In addition the Board has responsibilities for:


Requirements/evaluation of optimal training and training programmes in institutions.

Core Competencies Working Group: now closed

Authors: Runolfur Palsson, John Kellett, Stefan Lindgren, Jaime Merino, Colin Semple, Daniel Sereni.    
Eur J Int Med 2007; 18: 104-108. 

Core competencies of the European Internist: A discussion paper (PDF)

In an attempt to enhance the quality of internal medicine practice and to reform the education of internists across Europe, the European Board of Internal Medicine (formed by EFIM and UEMS) has launched a project aimed at defining core competencies that are common to all internists.  The compilation of six core competencies presented in this paper consists of patient care; medical knowledge; communication skills; professionalism, ethical and legal issues; organizational planning and service management skills; and academic activities.  These core competencies are the foundation required for the provision of high-quality medical care everywhere, regardless of the professional traditions and organization of health care in different countries.  The authors hope this paper will stimulate constructive discussion and thoughtful debate, and that it will be followed by a collaborative effort to develop and endorse a European consensus.

Professional Issues and the Quality of Care (now closed)

This working group has been merged with the Professional Issues WG.
The working group on Quality of Care and Professional Issues signals and investigates professional issues on Internal medicine throughout Europe.
The working group formulates and publishes position papers on behalf of EFIM.”


  • Mark H.H. Kramer (chairman) Netherlands
  • Werner Bauer                            Switzerland
  • Monica Bivol                             Norway
  • Dror Dicker                              Israel
  • Mine Durusu Tanriover               Turkey
  • Faustino Ferreira                       Portugal
  • Harry van Hulsteijn                    Netherlands
  • Antonio Martins Baptista             Portugal
  • Narciso Oliveira                         Portugal
  • Shirley Rigby                            United Kingdom
  • Xavier Roux                              France
  • Petra-Maria Schumm-Draeger    Germany
  • Frauke Weidanz                         United Kingdom

Up until now the WG published 4 position papers:

During the last working party meeting on September 26th  in Tartu, Estonia the WG:

1. finalized a position paper on ‘General internal medicine in academia’. It will be submitted for publication in the European Journal of Internal Medicine.
 2. Initiated a first draft on ‘Quality standards in Internal medicine’.

The next meeting was held in Cyprus in April 2015.

Past Project: EQUIP

Aim:  To improve professional quality of internists.

Slogan:  Quality is the core business of internal medicine as defined by safety, effectiveness, efficiency and patient-centered medical care.


Download the document (PDF format - 33,3 Kb) (PDF)

  • Gold standard for quality in practising internal medicine
  • “Rule of ten”.- Immediate discharge document
  • “Rule of twelve”.- Peer inspection of practices by national societies.

Download the document (PDF format - 50,8 Kb) (PDF)

  • Development of evidence based clinical guidelines by national societies based on the AGREE criteria (
  • European quality indicator project (EQUIP)

Quality is the core business of internal medicine as defined by safety, effectiveness, efficiency and patient-centred medical care. To assess the quality of care, indicators should be developed by a rigorous, standardized method and measured in internal medicine practice in Europe.  
Therefore the working group on Quality of Care used an ICT type RAND modified Delphy to extract indicators from evidence based guidelines.
 The following conditions should be met:
 Data collection should be webbased, easy to extract, gather and understood and user friendly. The indicators should be based on recommendations from clinical evidence-based guidelines. Preferably ICT approachable databases should be the source of information with patient records or patient surveys as second best. The setting of the study is the outpatient clinic or the emergency unit.
 First 7 internal diseases were selected, and 20 indicators defined. Following a survey amongst EFIM members and further analysis and discussions in the group, the indicators were reduced to 6 for 3 diseases: 2 for diabetes mellitus, 2 for cardiovascular risk management, and 2 for hypertension.
 For each of the indicators, the following scheme was filled in:
•Description and relevance with evidence level
•Definition of nominator and denominator with data source
•In- and exclusion criteria
•Adjustments (sociodemographic or for case mix)
•Mean or median score and variance
•Minimum and Optimal level

 Before analysing these indicators in at least 5 European countries a check on measurability has to be performed, because it is known that during such a check half of the indicators are either not registred, have an alternative administration definition or important other clinical criteria cannot be found. For this data check on traceability and validity the intention is to analyse 30 samples per indicator from 3 types of practices in the Netherlands (one University Hospital practice, one large and one small teaching hospital): a feasibility study. As it is known that the measurement, registration and tabulation of one indicator usually take a bit less than 30 minutes the sampling of 180 indicators will take 100 hours. If an epidemiologist performs the job at a salary of 100 euros per hour, the feasibility study will cost 10.000 euros.

Past Chair: Professional Issues and the Quality of Care Working Group
Mark H.H. Kramer, MD PhD FRCP FACP Professor of Medicine | Chair department of Internal Medicine
 VU University Medical Center
 Visiting address: De Boelelaan 1117 (Room 4 A 34)
 phone: +31(0)20-4444309 | fax: +31(0)20-4444313 


Medical Professionalism

The MPP project was a joint venture between the American Board of Internal Medicine/American College of Physicians - American Society of Internal Medicine and the European Federation of Internal Medicine (ABIM/ACP-ASIM and EFIM).  The working group consisted of 6 members from each organisation who met periodically between 1999 and 2001 to formulate the Physician’s Charter.  Thiswhich was jointly published in the Annals of Internal Medicine (ref: Ann Int Med 2002; 136: 243-6), in the Lancet (ref: Lancet 2002; 359: 520-2), and in the European Journal of Internal Medicine (ref: Eur J Int Med 2002; 13: 215-9) entitled: 'Charter on medical professionalism.  Medical professionalism in the new millennium: a physician’s charter'. 

Charter on medical professionalism Medical professionalism in the new millennium:  A physician’s charter.  Project of the ABIM Foundation, ACP-ASIM Foundation and the European Federation of Internal Medicine. (Ann Int Med 2002; 136: 243-6)

Charter on medical professionalism. Where do we go from here?  
Editorial by Dr Christopher Davidson (EJIM 2002; 13: 153)

On closer reading of A Physician’s Charter: Medical Professionalism in the New Millennium, it is clear that the institutional and organizational settings of contemporary medical practice pose significant impediments to achieving several of the responsibilities it calls on physicians to assume.  Moreover, many of those impediments are so deeply imbedded in the structure of all healthcare systems that they are beyond the control of physicians, whether acting alone or collectively.  Indeed, only those in a position to effect system-wide changes (eg. elected officials, ministers of heath) can eliminate these structural impediments.  Consequently, if the public is to continue to enjoy the unique benefits that medical professionalism can offer, some form of a functional alliance between the medical profession and society is necessary. 
The follow up article: Alliance Between Society and Medicine: The Public's Stake in Medical Professionalism was published in JAMA 

Medical Professionalism Project. Alliance Between Society and Medicine: The Public's Stake in Medical Professionalism.
Authors: JJ Cohen, S Cruess, C Davidson (JAMA 2007; 298: 670-673)


Peripheral Arterial Disease

The EFIM Peripheral Arterial Disease (PAD) Working Group was set up to address the widespread failure to recognise PAD as an important risk factor for future vascular events such as stroke and myocardial infarction. Such patients are often only seen by a vascular surgeon when symptoms become apparent at a late stage in the disease. The Working group brought together opinion leaders in vascular and internal medicine with an unrestricted grant from Bristol Myers Squibb. They met from 2007-8 and produced several documents which are available for download below. The key findings were:

  • PAD affects approximately 16% of the general population aged over 55 years in Europe and North America and is on the increase. 
  • Almost one-third of all patients with PAD around the world are under internist care.
  • PAD is not just a localised disease – it also has serious systemic effects and is a major cause of death and disability.
  • Individuals with PAD have higher risk of serious cardiovascular events within 1 year of diagnosis than those with CAD or CVD – yet physicians and patients are less aware of the risks associated with PAD than of those of MI or ischaemic stroke.
  • More than 20% of individuals with PAD in the general population do not show classical symptoms and are diagnosed through ABI measurement alone – the proportion is much higher in at-risk populations.
  • ABI is a quick, simple and accurate non-invasive test for PAD that can be performed in an office environment by any trained physician or nurse.
  • Early diagnosis and prompt risk factor management to established guidelines can greatly diminish PAD-related disability and death.

Publications from the PAD Working Group:

Peripheral arterial disease: A growing problem for the internist.
Eur J Int Med 2009; 20: 132-138 download pdf (PDF)

Peripheral Arterial Disease Management. A Practical Guide for Internists (May 2008)
download the Booklet (PDF)


Political Issues in Internal Medicine

Report from the EFIM Working Group on Professional Issues in Internal Medicine  Two reports have now been published: in 2005 and in 2010, please see below:

What will be the future of internal medicine in Europe? Because of rapidly growing concerns regarding the position of internal medicine in many European countries, the European Federation of Internal Medicine (EFIM) has established a working group to analyze the situation. 

 Being well aware of the variation in working practices in the different countries, the members of the group used an "all-European" approach to answer the following questions:

· Are there problems for internal medicine? If so, what are these problems and why? 
· Why do the health care systems in the European countries need internal medicine? 
· Why do patients need internal medicine? 
· What needs to be done?

Internal medicine is the modern, clinical, and scientific medical discipline that is responsible for the care of adult patients with one or more complex, acute, or chronic illnesses. Internal medicine is the cornerstone of an integrated health care delivery service that is needed today. Decision-makers in politics and hospitals, insurers, journalists, and the general public need a better understanding of what internal medicine can offer to the health care system and to the individual patient.

EFIM recommends wide publication of the two reports (see below) via national society websites and journals with translation where appropriate. EFIM owns the copyright and any additional journal publications should be notified to: 
Dr JWF Elte, EFIM Secretary-General  

1st Report from the EFIM Working Group on Professional Issues in Internal Medicine 
Political issues in Internal Medicine in Europe: A position paper
Chairman/Principal Author: Werner Bauer 
Members: Petra-Maria Schumm-Draeger; Johannes Koebberling; Thomas Gjoerup; Jose Javier Garcia Alegria; Faustino Ferreira; Clare Higgens; Werner Bauer; Giuseppe Licata; Moshe Mittelman; James O'Hare; Serhat Ünal.
Eur J Int Med 2005; 16: 214-217

2nd Report from the EFIM Working Group on Professional Issues in Internal Medicine 
Internal Medicine in Europe: How to cope with the future?
An official EFIM strategy document
Chairman/Principal Author: Mark Kramer
Members: Mark Kramer, Erdal Akalin, Melchor Alvarez de Mon Soto, Haim Bitterman, Faustino Ferreira, Clare Higgens; Petra-Maria Schumm-Draeger, Johannes Koebberling, Mine Durusu Tanriover, Werner Bauer.
Eur J Int Med 2010; 21: 173-175


Scientific Committee (joint with FDIME)

Chairman: Loic Guillevin(FR

Objectives: to promote clinical research in Internal Medicine on a European basis. 




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