In order to encourage general internal medicine (GIM) as a specialty we must learn from our peers outside the UK
Editor – It was heartening to read Kirthi et al's article (Clin Med August 2012 pp316–19) concerning the debate surrounding the role of the general physician in the UK.
Amongst others, the UK is facing two main challenges in healthcare provision: an ageing population and an obesity epidemic. Both old age and obesity are associated with increasing comorbidities such as diabetes and hypertension. However, it is not only within the confines of the inpatient setting that this demographic will be seen. Outpatient and primary care services will likely be dealing with the majority of people with complex multiple comorbidities. Moreover, it is not only physicians who will be affected, but allied healthcare and social services professionals as well.
As Kirthi et al's article rightly reflects, shared care and pooling of resources – as has occurred on orthopaedic wards with involvement of geriatricians – is an important step forward. However, roll-out of ‘shared care’ requires a body of generalists and support for the general physician as a specialist that appears to be thriving in countries such as the US and others within Europe, but is absent in the UK.
Having recently attended a European Society of Internal Medicine conference (ESIM 2011), it was encouraging to see the pride that certain EU countries (eg France and Spain) take in becoming a generalist in its purest sense, ie not a geriatrician, not an acute medical physician, but a ‘general internal physician’. This distinction will be essential in shaping an evolving healthcare provision for those with multiple comorbidities, as will a potential redefining of what constitutes ‘geriatric medicine’ – an excellent specialty in its own right – in the modern day of longevity of life span. Where would be the arbitrary cut-off for review by a generalist as opposed to a geriatrician? Aged 75 years? Or would a generalist see patients of all ages?
In order to encourage general internal medicine (GIM) as a specialty we must learn from our peers outside the UK. Essential conditions for promoting GIM would include:
viewing it as an ‘ology’ – a specialism in its own right – and according it the prestige it deserves
educating medical students about the role of the generalist in hospital medicine
involving role models for medical students and junior doctors to look up to in order to consider pursuing a career as a generalist
ensuring reasonable working conditions to avoid the job dissatisfaction, noted in Kirthi et al's article, in medical registrars who are essentially on-call, albeit acute, generalists
promoting and fully utilising such GIM bodies as the Royal College of Physicians and ESIM.
Future provision of care for an ageing population will require not only the above but also a bridge between hospital and community services that incorporates cohesive multi-disciplinary team input. We must put behind us the days in which a patient with multi-system complaints and health needs may be passed between multiple specialties prior to any formal diagnoses due to their condition ‘not being my specialty’.
Humans are complex organisms that, as they age, require a generalist approach. This is currently missing in UK medicine.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- © 2012 Royal College of Physicians
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